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Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","code_information":[{"code":"011","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59542.41,"maximum":112200.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85067.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98397.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94192.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88901.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59542.41},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71377.81},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":112200.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74571.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108809.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96373.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82155.11},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93676.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","code_information":[{"code":"020","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":85903.69,"maximum":161875.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":122729.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141961.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":135894.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128261.44},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85903.69},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102978.99},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":161875.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107587.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":156982.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":139041.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118527.73},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135149.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures With Mcc","code_information":[{"code":"028","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":65592.61,"maximum":123601.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93711.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108395.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103763.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97935.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65592.61},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78630.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":123601.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82149.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119865.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106166.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90503.02},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103194.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures Without Cc/Mcc","code_information":[{"code":"036","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21209.55,"maximum":39967.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30301.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35050.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33552.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31667.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21209.55},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25425.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39967.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26563.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38758.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34329.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29264.4},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33368.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries Without Cc/Mcc","code_information":[{"code":"053","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10689.93,"maximum":20143.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15272.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17665.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16910.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15960.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10689.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12814.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20143.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13388.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19535.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17302.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14749.69},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16818.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","code_information":[{"code":"061","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30099.26,"maximum":56718.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43002.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49740.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47615.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44940.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30099.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36082.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":56718.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37696.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55004.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48717.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41530.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47354.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transient Ischemia Without Thrombolytic","code_information":[{"code":"069","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8720.5,"maximum":16432.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12458.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14411.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13795.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13020.44},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8720.5},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10453.9},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16432.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10921.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15936.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14114.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12032.32},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13719.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nontraumatic Stupor And Coma With Mcc","code_information":[{"code":"080","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19759.77,"maximum":37235.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28230.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32654.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31258.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29503.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19759.77},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23687.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37235.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24747.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36109.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31982.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27264.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31087.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Mcc","code_information":[{"code":"088","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14757.6,"maximum":27809.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21084.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24387.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23345.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22034.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14757.6},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17691.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27809.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18482.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26968.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23886.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20362.16},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23217.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","code_information":[{"code":"096","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28157.13,"maximum":53058.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40227.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46531.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44542.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42040.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28157.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33753.99},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53058.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35264.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51455.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45574.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38850.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44298.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures With Cc/Mcc","code_information":[{"code":"113","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25666.96,"maximum":48366.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36670.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42416.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40603.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38322.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25666.96},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30768.85},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":48366.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32145.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46904.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41543.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35414.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40380.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","code_information":[{"code":"124","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14444.28,"maximum":27218.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20636.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23870.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22849.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21566.53},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14444.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17315.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27218.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18090.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26395.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23379.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19929.86},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22724.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Cc","code_information":[{"code":"141","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23811.07,"maximum":44869.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34018.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39349.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37667.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35551.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23811.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28544.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44869.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29821.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43512.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38540.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32853.91},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37461.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dysequilibrium","code_information":[{"code":"149","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8205.22,"maximum":15461.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11722.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13559.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12980.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12251.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8205.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9836.19},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15461.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10276.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14994.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13280.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11321.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12908.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Mcc","code_information":[{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18742.31,"maximum":35317.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26776.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30972.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29649.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27983.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18742.31},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22467.76},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35317.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23473.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34250.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30335.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25860.16},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29486.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"168","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14916.99,"maximum":28109.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21311.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24651.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23597.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22272.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14916.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17882.08},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28109.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18682.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27259.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24144.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20582.08},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23468.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Cc","code_information":[{"code":"181","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11692.11,"maximum":22032.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16704.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19321.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18496.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17457.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11692.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14016.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22032.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14643.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21366.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18924.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16132.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18394.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Edema And Respiratory Failure","code_information":[{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13486.86,"maximum":25414.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19268.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22287.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21335.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20137.02},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13486.86},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16167.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25414.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16891.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24646.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21829.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18608.83},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21218.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":17556.12,"10th_percentile":17556.12,"90th_percentile":17556.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":19080.21,"10th_percentile":19080.21,"90th_percentile":19080.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":20722.45,"10th_percentile":2388.41,"90th_percentile":27928.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":13182.61,"10th_percentile":13182.61,"90th_percentile":13182.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13318.66,"10th_percentile":13318.66,"90th_percentile":13318.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease With Cc","code_information":[{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10361.32,"maximum":19524.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14803.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17122.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16390.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15470.33},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10361.32},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12420.87},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19524.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12976.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18934.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16770.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14296.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16301.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses With Mcc","code_information":[{"code":"205","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19989.03,"maximum":37667.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28558.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33033.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31621.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29845.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19989.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23962.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37667.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25034.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36528.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32353.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27580.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31448.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","code_information":[{"code":"216","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":106798.83,"maximum":201250.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":152582.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":176491.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":168948.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":159459.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106798.83},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128027.5},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":201250.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133756.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195166.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172862.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147358.32},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168023.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca With Mcc","code_information":[{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":92029.22,"maximum":173418.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":131481.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":152083.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145584.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137407.37},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92029.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110322.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":173418.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115258.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":168176.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148956.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126979.58},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144786.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","code_information":[{"code":"241","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15113.49,"maximum":28479.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21592.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24975.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23908.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22565.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15113.49},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18117.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28479.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18928.36},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27618.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24462.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20853.22},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23777.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures With Cc","code_information":[{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28336.17,"maximum":53396.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40483.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46827.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44826.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42308.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28336.17},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33968.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53396.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35488.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51782.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45864.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39097.52},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44580.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement With Cc","code_information":[{"code":"261","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20638.59,"maximum":38891.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29486.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34106.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30815.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20638.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24740.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38891.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37715.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33405.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28476.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32470.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","code_information":[{"code":"269","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46104.67,"maximum":86879.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65869.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76190.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72934.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68838.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46104.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55269.02},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86879.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57742.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84252.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74623.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63614.06},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72534.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Mcc","code_information":[{"code":"277","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50420.16,"maximum":95011.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72034.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83322.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79761.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75281.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50420.16},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60442.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":95011.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63146.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92139.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81608.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69568.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79324.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired Without Cc/Mcc","code_information":[{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6538.19,"maximum":12320.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9341.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10804.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10343.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9762.07},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6538.19},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7837.8},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12320.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8188.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11948.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10582.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9021.23},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10286.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock Without Cc/Mcc","code_information":[{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6179.02,"maximum":11643.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8827.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10211.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9774.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9225.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6179.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7407.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11643.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7738.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11291.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10001.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8525.66},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9721.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis Without Mcc","code_information":[{"code":"303","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7349.32,"maximum":13848.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10499.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12145.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11626.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10973.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7349.32},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8810.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13848.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9204.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13430.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11895.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10140.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11562.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":2002.2,"10th_percentile":2002.2,"90th_percentile":2002.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Angina Pectoris","code_information":[{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7662.64,"maximum":14439.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10947.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12662.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12121.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11440.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7662.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9185.77},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14439.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9596.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14002.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12402.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10572.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12055.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endovascular Cardiac Valve Procedures With Mcc","code_information":[{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":48721.48,"maximum":91810.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69607.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80515.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77074.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72745.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48721.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58405.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":91810.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61019.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89034.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78859.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67224.66},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76651.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Cc","code_information":[{"code":"327","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26683.33,"maximum":50281.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38122.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44095.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42211.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39840.46},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26683.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31987.25},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50281.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33418.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48761.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43189.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36816.98},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41979.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Mcc","code_information":[{"code":"335","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38983.52,"maximum":73460.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55695.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64422.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61669.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58205.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38983.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46732.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73460.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48823.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71239.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63097.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53788.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61331.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures Without Cc/Mcc","code_information":[{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9504.34,"maximum":17909.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13578.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15706.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15035.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14190.78},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9504.34},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11393.54},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17909.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11903.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17368.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15383.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13113.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14952.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures With Cc","code_information":[{"code":"357","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25387.48,"maximum":47839.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36270.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41954.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40161.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37905.65},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25387.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30433.82},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47839.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31795.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46393.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41091.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35029.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39941.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","code_information":[{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11146.26,"maximum":21003.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15924.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18419.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17632.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16642.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11146.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13361.83},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21003.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13959.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20368.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18041.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15379.32},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17536.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":15150.75,"10th_percentile":15150.75,"90th_percentile":15150.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Mcc","code_information":[{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21421.34,"maximum":40366.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30604.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35400.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33887.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31983.86},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21421.34},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25679.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40366.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26828.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39145.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34672.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29556.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33701.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction With Mcc","code_information":[{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16122.23,"maximum":30380.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23033.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26642.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25504.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24071.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16122.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19326.88},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30380.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20191.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29462.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26095.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22245.04},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25364.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":14381.59,"10th_percentile":14381.59,"90th_percentile":14381.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Mcc","code_information":[{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26145.12,"maximum":49267.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37353.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43206.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41359.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39036.87},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26145.12},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31342.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49267.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32744.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47778.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42317.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36074.38},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41133.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Cc","code_information":[{"code":"409","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23769.58,"maximum":44791.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33959.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39280.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37601.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35489.99},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23769.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28494.33},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44791.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29769.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43437.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38472.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32796.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37395.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","code_information":[{"code":"417","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26052.33,"maximum":49092.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37220.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43053.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41213.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38898.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26052.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31230.82},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49092.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32628.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47608.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42167.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35946.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40987.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":18315.64,"10th_percentile":18315.64,"90th_percentile":18315.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":35443.12,"10th_percentile":35443.12,"90th_percentile":35443.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","code_information":[{"code":"425","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16378.78,"maximum":30863.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23400.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27066.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25910.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24454.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16378.78},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19634.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30863.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20513.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29930.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26510.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22599.02},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25768.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7778.36,"maximum":14657.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11112.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12854.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12304.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11613.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7778.36},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9324.49},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14657.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9741.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14214.38},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12589.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10732.39},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12237.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","code_information":[{"code":"442","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10538.18,"maximum":19858.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15055.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17414.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16670.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15734.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10538.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12632.88},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19858.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13198.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19257.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17056.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14540.31},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16579.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5414.08,"10th_percentile":5414.08,"90th_percentile":5414.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35266.28,"maximum":66455.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50384.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58279.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55789.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52655.52},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35266.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42276.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66455.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44168.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64446.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57081.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48659.52},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55483.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement Or Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With","code_information":[{"code":"465","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19909.33,"maximum":37516.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28444.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32901.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31495.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29726.31},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23866.76},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37516.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24934.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36382.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32224.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27470.39},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":19021.23,"10th_percentile":19021.23,"90th_percentile":19021.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion Without Cc/Mcc","code_information":[{"code":"473","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26651.67,"maximum":50222.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38076.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44043.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42161.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39793.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26651.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31949.29},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50222.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33378.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48703.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43137.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36773.3},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41930.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Cc","code_information":[{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22865.66,"maximum":43087.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32667.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37786.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36172.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34140.35},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22865.66},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27410.72},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43087.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28637.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41785.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37009.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31549.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35973.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":10631.11,"10th_percentile":10631.11,"90th_percentile":10631.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":9009.98,"10th_percentile":9009.98,"90th_percentile":9009.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc Or Insertion Of Antibioti","code_information":[{"code":"492","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40082.86,"maximum":75531.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57265.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66239.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63408.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59847.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40082.86},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48050.23},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":75531.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50200.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73248.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64877.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55305.31},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63061.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures With Mcc","code_information":[{"code":"500","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34550.12,"maximum":65105.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49361.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57096.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54656.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51586.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34550.12},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41417.74},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65105.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43271.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63137.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55922.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47671.38},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54356.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","code_information":[{"code":"508","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16532.7,"maximum":31154.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23620.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27321.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26153.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24684.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16532.7},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19818.95},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31154.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20705.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30212.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26759.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22811.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26010.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","code_information":[{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16776.15,"maximum":31612.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23967.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27723.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26538.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25048.21},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16776.15},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20110.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31612.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21010.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30657.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27153.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23147.31},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26393.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Hip And Pelvis With Mcc","code_information":[{"code":"535","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13995.59,"maximum":26373.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19995.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23128.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22140.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20896.6},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13995.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16777.53},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26373.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17528.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25575.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22652.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19310.77},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22018.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","code_information":[{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11222.68,"maximum":21147.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16033.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18546.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17753.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16756.4},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11222.68},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13453.44},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21147.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14055.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20508.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18164.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15484.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17656.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6009.57,"10th_percentile":6009.57,"90th_percentile":6009.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":2204.26,"10th_percentile":2204.26,"90th_percentile":2204.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems With Mcc","code_information":[{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18297.98,"maximum":34480.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26142.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30238.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28946.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27320.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18297.98},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21935.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34480.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22916.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33438.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29616.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25247.09},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28787.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20359.11,"maximum":38364.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29086.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33644.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32206.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30397.87},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20359.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24405.95},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38364.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25498.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37204.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32952.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28090.99},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32030.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Mcc","code_information":[{"code":"570","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32107.99,"maximum":60503.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45872.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53060.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50792.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47939.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32107.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38490.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":60503.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40212.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58674.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51969.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44301.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50514.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17537.07,"maximum":33046.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25055.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28981.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27742.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26184.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17537.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21022.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33046.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21963.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32047.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28385.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24197.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27590.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers With Mcc","code_information":[{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21127.67,"maximum":39812.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30184.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34914.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33422.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31545.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21127.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25327.27},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39812.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26460.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38609.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34196.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29151.42},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33239.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Malignant Breast Disorders With Cc/Mcc","code_information":[{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11371.15,"maximum":21427.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16245.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18791.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17988.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16978.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11371.15},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13631.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21427.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14241.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20779.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18405.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15689.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17889.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Adrenal And Pituitary Procedures With Cc/Mcc","code_information":[{"code":"614","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23927.88,"maximum":45089.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34185.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39542.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37852.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35726.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23927.88},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28684.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45089.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29967.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43726.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38729.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33015.08},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37644.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","code_information":[{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38855.79,"maximum":73219.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55512.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64211.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61467.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58014.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38855.79},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46579.25},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73219.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48663.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71006.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62891.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53612.23},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61130.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","code_information":[{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15933.36,"maximum":30024.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22763.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26330.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25205.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23789.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15933.36},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19100.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30024.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19955.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29117.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25789.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21984.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25067.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Cc","code_information":[{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11189.93,"maximum":21086.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15986.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18492.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17701.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16707.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11189.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13414.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21086.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14014.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20448.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18111.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15439.58},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17604.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Mcc","code_information":[{"code":"656","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34757.54,"maximum":65496.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49657.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57438.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54984.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51895.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34757.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41666.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65496.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43530.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63516.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56257.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47957.58},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54682.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures Without Cc/Mcc","code_information":[{"code":"664","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11429.01,"maximum":21536.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16328.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18887.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18079.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17064.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11429.01},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13700.78},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21536.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14313.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20885.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18498.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15769.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17980.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures Without Cc/Mcc","code_information":[{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11784.9,"maximum":22207.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16836.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19475.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18642.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17595.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11784.9},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14127.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22207.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14759.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21536.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19074.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16260.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18540.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms With Cc","code_information":[{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11438.83,"maximum":21555.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16342.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18903.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18095.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17079.14},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11438.83},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13712.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21555.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14326.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20903.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18514.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15783.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17996.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Stricture","code_information":[{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11766.34,"maximum":22172.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16810.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19444.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18613.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17568.14},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11766.34},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14105.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22172.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14736.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21502.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19044.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16234.9},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18511.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Testes Procedures With Cc/Mcc","code_information":[{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22748.84,"maximum":42867.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32501.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37593.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35987.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33965.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22748.84},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27270.69},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42867.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28490.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41571.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36820.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31388.28},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35789.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System With Mcc","code_information":[{"code":"722","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19756.49,"maximum":37228.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28225.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31253.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29498.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19756.49},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23683.54},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37228.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24743.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36103.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31977.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27259.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31082.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses Without Cc/Mcc","code_information":[{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7336.22,"maximum":13824.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10481.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12123.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11605.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10953.6},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7336.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8794.46},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13824.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9187.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13406.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11874.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10122.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11541.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","code_information":[{"code":"741","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15568.73,"maximum":29337.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22242.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25728.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24628.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23245.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15568.73},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18663.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29337.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19498.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28450.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25199.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21481.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24493.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures With Cc/Mcc","code_information":[{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28030.49,"maximum":52820.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40046.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46322.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44342.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41851.88},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28030.49},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33602.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":52820.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35105.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51223.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45369.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38675.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44099.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Menstrual And Other Female Reproductive System Disorders With Cc/Mcc","code_information":[{"code":"760","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10998.88,"maximum":20726.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15713.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18176.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17399.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16422.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10998.88},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13185.15},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20726.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13775.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20099.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17802.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15175.97},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17304.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Cc","code_information":[{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11573.11,"maximum":21808.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16534.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19125.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18307.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17279.63},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11573.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13873.53},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21808.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14494.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21149.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18731.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15968.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18207.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prematurity Without Major Problems","code_information":[{"code":"792","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26737.92,"maximum":50384.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38200.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44186.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42297.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39921.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26737.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32052.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50384.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33486.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48861.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43277.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36892.3},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42065.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":5514.0,"10th_percentile":5514.0,"90th_percentile":5514.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3473.45,"10th_percentile":3473.45,"90th_percentile":3473.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":3470.81,"10th_percentile":3470.81,"90th_percentile":3470.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8546.8,"10th_percentile":8546.8,"90th_percentile":8546.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":3072.0,"10th_percentile":3072.0,"90th_percentile":3072.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Cc","code_information":[{"code":"800","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30670.22,"maximum":57794.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43818.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50684.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48518.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45793.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30670.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36766.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":57794.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38411.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56047.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49642.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42317.99},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48252.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24103.64,"maximum":45420.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34436.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39832.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38130.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35988.77},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24103.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28894.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45420.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30187.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44047.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39013.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33257.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37921.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders Without Cc/Mcc","code_information":[{"code":"816","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6899.54,"maximum":13001.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9857.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11401.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10914.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10301.6},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6899.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8270.98},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13001.42},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8641.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12608.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11167.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9519.82},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10854.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","code_information":[{"code":"824","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24733.56,"maximum":46607.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35336.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40873.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39126.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36929.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24733.56},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29649.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46607.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30976.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45198.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40033.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34126.73},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38912.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Cc","code_information":[{"code":"832","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7877.71,"maximum":14844.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11254.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13018.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12462.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11762.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7877.71},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9443.58},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14844.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9866.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14395.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12750.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10869.46},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12393.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7195.76,"10th_percentile":7195.76,"90th_percentile":7195.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Mcc","code_information":[{"code":"840","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35315.4,"maximum":66547.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50454.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58360.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55866.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52728.87},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35315.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42335.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66547.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44229.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64536.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57160.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48727.3},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55560.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9272.9,"maximum":17473.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13248.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15324.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14669.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13845.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9272.9},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11116.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17473.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11613.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16945.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15008.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12794.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14588.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"858","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15206.29,"maximum":28654.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21725.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25129.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24055.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22704.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15206.29},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18228.88},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28654.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19044.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27788.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24612.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20981.25},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23923.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","code_information":[{"code":"869","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7966.13,"maximum":15011.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11381.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13164.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12601.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11894.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7966.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.58},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15011.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9976.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14557.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12893.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10991.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12532.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Personality And Impulse Control","code_information":[{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21466.1,"maximum":40450.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30668.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35474.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33958.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32050.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21466.1},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25732.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40450.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26884.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39227.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34744.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29618.38},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33771.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","code_information":[{"code":"897","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9637.53,"maximum":18160.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13769.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15926.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15245.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14389.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9637.53},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11553.2},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18160.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12070.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17611.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15599.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13297.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15162.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11133.12,"10th_percentile":11133.12,"90th_percentile":11133.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":11771.0,"10th_percentile":11771.0,"90th_percentile":11771.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8111.09,"10th_percentile":8111.09,"90th_percentile":8111.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13388.58,"10th_percentile":13388.58,"90th_percentile":13388.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":16315.19,"10th_percentile":16315.19,"90th_percentile":16315.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":1118.2,"10th_percentile":1118.2,"90th_percentile":1118.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries With Cc","code_information":[{"code":"908","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21781.6,"maximum":41044.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31119.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35995.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34457.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32521.76},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21781.6},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26111.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41044.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27279.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39804.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35255.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30053.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34268.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":3163.16,"10th_percentile":3163.16,"90th_percentile":3163.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":30383.58,"10th_percentile":30383.58,"90th_percentile":30383.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment With Mcc","code_information":[{"code":"919","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19986.84,"maximum":37662.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28554.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33029.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31617.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29842.04},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19986.84},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23959.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37662.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25031.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36524.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32350.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27577.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31444.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":22700.99,"10th_percentile":22700.99,"90th_percentile":22700.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","code_information":[{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42512.98,"maximum":80110.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60737.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70255.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67252.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63475.46},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42512.98},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50963.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":80110.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53243.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77689.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68810.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58658.33},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66884.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms With Mcc","code_information":[{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13858.04,"maximum":26113.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19798.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22901.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21922.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20691.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13858.04},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16612.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26113.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17356.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25324.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22430.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19120.97},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21802.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma With Cc","code_information":[{"code":"958","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46003.15,"maximum":86687.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65724.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76022.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72774.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68686.57},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46003.15},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55147.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86687.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57615.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84067.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74459.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63473.98},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72375.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Cc","code_information":[{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14137.52,"maximum":26640.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20198.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23363.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22364.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21108.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14137.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16947.67},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26640.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25835.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22882.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19506.59},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22242.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"989","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13091.67,"maximum":24669.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18703.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21634.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20710.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19546.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13091.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15693.93},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24669.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16396.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23924.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21189.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18063.55},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20596.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Liver Transplant With Mcc Or Intestinal Transplant","code_information":[{"code":"005","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":112559.73,"maximum":212106.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":160812.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":186011.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":178062.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":168061.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112559.73},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134933.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":212106.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":140971.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":205694.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":182186.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":155307.06},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177086.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allogeneic Bone Marrow Transplant","code_information":[{"code":"014","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":131199.41,"maximum":247230.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":187443.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":216814.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":207549.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195891.77},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131199.41},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157278.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":247230.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":164316.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":239757.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":212356.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":181025.63},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":206411.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","code_information":[{"code":"023","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62557.69,"maximum":117882.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89375.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103380.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98962.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93403.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62557.69},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74992.44},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":117882.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78348.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114319.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101254.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86315.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98419.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Mcc","code_information":[{"code":"031","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":48913.62,"maximum":92172.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69882.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80832.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77378.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73032.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48913.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58636.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":92172.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61260.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89385.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79170.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67489.77},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76954.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures Without Cc/Mcc","code_information":[{"code":"039","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12832.93,"maximum":24182.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18334.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21207.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20300.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19160.65},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12832.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15383.77},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24182.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16072.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23451.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20771.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.56},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20189.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders With Mcc","code_information":[{"code":"056","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25361.28,"maximum":47790.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36233.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41911.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40119.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37866.53},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25361.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30402.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47790.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31762.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46345.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41049.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34992.86},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39900.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":9135.57,"10th_percentile":9135.57,"90th_percentile":9135.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","code_information":[{"code":"064","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21954.09,"maximum":41370.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31365.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36280.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34729.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32779.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21954.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26317.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41370.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27495.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40119.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35534.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30291.69},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34539.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders Without Cc/Mcc","code_information":[{"code":"072","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8255.44,"maximum":15556.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11794.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13642.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13059.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12326.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8255.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9896.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15556.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10339.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15086.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13362.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11390.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12988.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour With Cc","code_information":[{"code":"083","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15237.95,"maximum":28714.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21770.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25181.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24105.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22751.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15237.95},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18266.83},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28714.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19084.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27846.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24663.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21024.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23973.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Mcc","code_information":[{"code":"091","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19172.44,"maximum":36128.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27391.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31683.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30329.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28626.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19172.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22983.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36128.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24011.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35036.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31032.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26453.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30163.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","code_information":[{"code":"099","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14873.32,"maximum":28027.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21249.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24579.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23528.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22207.12},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14873.32},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17829.73},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28027.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18627.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27179.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24073.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20521.83},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23399.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures With Cc/Mcc","code_information":[{"code":"116","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19739.03,"maximum":37195.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28200.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32619.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31225.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29472.03},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19739.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23662.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37195.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24721.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36071.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31949.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27235.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31054.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures Without Cc/Mcc","code_information":[{"code":"136","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11084.03,"maximum":20886.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15835.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18317.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17534.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16549.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11084.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13287.23},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20886.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13881.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20255.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17940.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15293.46},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17438.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","code_information":[{"code":"144","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18918.07,"maximum":35648.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27028.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31263.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29927.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28246.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18918.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22678.46},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35648.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23693.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34571.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30620.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26102.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29763.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri With Mcc","code_information":[{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12906.08,"maximum":24320.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18438.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21328.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20416.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19269.86},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12906.08},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15471.45},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24320.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16163.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23584.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20889.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17807.48},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20304.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Mcc","code_information":[{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":48927.81,"maximum":92198.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":69902.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80856.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77400.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73053.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48927.81},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58653.32},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":92198.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61277.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89411.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79193.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67509.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76976.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Embolism Without Mcc","code_information":[{"code":"176","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8788.19,"maximum":16560.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12555.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14523.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13902.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13121.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8788.19},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10535.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16560.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11006.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16059.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14224.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12125.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13826.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":9475.34,"10th_percentile":9475.34,"90th_percentile":9475.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma With Cc","code_information":[{"code":"184","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11616.78,"maximum":21890.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16596.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19197.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18377.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17344.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11616.78},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13925.88},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21890.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14549.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21228.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18802.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16028.54},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18276.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","code_information":[{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7008.71,"maximum":13207.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10013.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11582.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11087.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10464.6},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7008.71},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8401.85},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13207.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8777.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12807.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11344.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9670.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11026.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax With Cc","code_information":[{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12001.06,"maximum":22614.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17145.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19832.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18984.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17918.59},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12001.06},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14386.54},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22614.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15030.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21931.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19424.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16558.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18880.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","code_information":[{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30007.56,"maximum":56545.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42871.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49589.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47470.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44803.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30007.56},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35972.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":56545.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37581.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54836.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48569.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41403.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47209.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","code_information":[{"code":"219","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":83824.0,"maximum":157956.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":119758.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":138524.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132604.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":125156.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83824.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100485.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":157956.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104982.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":153182.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135675.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115658.23},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131877.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","code_information":[{"code":"234","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59636.3,"maximum":112377.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85201.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98552.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94340.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89042.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59636.3},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71490.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":112377.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74689.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108980.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96525.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82284.65},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93823.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","code_information":[{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19732.48,"maximum":37183.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28191.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32609.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31215.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29462.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19732.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23654.75},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37183.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24713.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36059.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31938.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27226.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31044.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","code_information":[{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18535.97,"maximum":34928.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26482.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30631.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29322.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27675.77},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18535.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22220.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34928.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23214.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33873.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30001.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25575.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29162.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System O.R. Procedures","code_information":[{"code":"264","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36469.33,"maximum":68722.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":52103.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60267.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57692.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54451.78},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36469.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43718.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":68722.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45674.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66644.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59028.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50319.46},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57375.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":14281.41,"10th_percentile":14281.41,"90th_percentile":14281.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures Without Cc/Mcc","code_information":[{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27871.1,"maximum":52519.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39819.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46058.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44090.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41613.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27871.1},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33411.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":52519.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34906.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50932.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45111.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38455.84},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43848.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Mcc","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17511.96,"maximum":32999.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25019.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28939.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27702.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26146.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17511.96},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20992.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32999.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21932.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32001.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28344.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24162.56},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27550.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4951.47,"10th_percentile":4951.47,"90th_percentile":4951.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":5802.78,"10th_percentile":5802.78,"90th_percentile":5802.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":9213.71,"10th_percentile":9213.71,"90th_percentile":9213.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis With Mcc","code_information":[{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29543.59,"maximum":55671.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42208.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48822.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46736.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44111.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29543.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35416.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":55671.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37000.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53988.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47818.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40763.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46479.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained Without Cc/Mcc","code_information":[{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4968.33,"maximum":9362.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":7098.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8210.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7859.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":7418.13},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4968.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5955.89},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":9362.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6222.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9079.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8041.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6855.17},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7816.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Congenital And Valvular Disorders With Mcc","code_information":[{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17203.01,"maximum":32417.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24577.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28429.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27214.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25685.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17203.01},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20622.49},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32417.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21545.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31437.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27844.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23736.28},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27064.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Mcc","code_information":[{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22764.13,"maximum":42896.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32522.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37619.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36011.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33988.76},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22764.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27289.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42896.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28510.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41599.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36845.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31409.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35814.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","code_information":[{"code":"322","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19246.67,"maximum":36268.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27497.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31806.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30447.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28736.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19246.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23072.38},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36268.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24104.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35171.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31152.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26556.07},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30280.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures With Cc","code_information":[{"code":"330","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26170.23,"maximum":49314.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37389.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43247.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41399.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39074.36},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26170.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31372.16},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49314.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32775.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47824.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42358.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36109.02},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41172.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":39518.63,"10th_percentile":39518.63,"90th_percentile":39518.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":18976.18,"10th_percentile":18976.18,"90th_percentile":18976.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":13715.83,"10th_percentile":9525.22,"90th_percentile":13759.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":12885.16,"10th_percentile":12885.16,"90th_percentile":12885.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":35604.41,"10th_percentile":35604.41,"90th_percentile":35604.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Mcc","code_information":[{"code":"344","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28196.43,"maximum":53133.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40283.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46596.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44604.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42099.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28196.43},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33801.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53133.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35313.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51526.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45638.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38904.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44360.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","code_information":[{"code":"352","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12748.87,"maximum":24023.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18214.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21068.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20167.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19035.14},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12748.87},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15283.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24023.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15966.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23297.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20635.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17590.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20057.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":15663.29,"10th_percentile":15663.29,"90th_percentile":15663.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","code_information":[{"code":"360","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26356.91,"maximum":49666.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37655.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43556.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41694.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39353.09},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26356.91},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31595.94},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49666.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33009.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48165.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42660.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36366.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41466.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy With Cc","code_information":[{"code":"375","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13205.2,"maximum":24883.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18866.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21822.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20889.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19716.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13205.2},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15830.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24883.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16538.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24131.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21373.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18220.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20775.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8118.26,"10th_percentile":8118.26,"90th_percentile":8118.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":11640.56,"10th_percentile":11640.56,"90th_percentile":11640.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer With Mcc","code_information":[{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15073.1,"maximum":28403.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21534.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24909.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23844.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22505.41},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15073.1},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18069.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28403.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18877.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27544.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24396.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20797.48},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23714.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","code_information":[{"code":"391","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13846.03,"maximum":26091.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19781.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22881.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21903.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20673.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13846.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16598.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26091.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17340.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25302.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22410.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19104.4},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21783.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":12627.46,"10th_percentile":12627.46,"90th_percentile":12627.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","code_information":[{"code":"402","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":43891.8,"maximum":82709.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62707.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72533.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69434.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65534.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43891.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52616.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":82709.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54970.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80208.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71042.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60560.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69053.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Cc","code_information":[{"code":"412","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22952.99,"maximum":43252.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32792.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37931.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36310.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34270.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22952.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27515.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43252.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28746.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41944.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37151.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31669.96},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36111.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures With Mcc","code_information":[{"code":"420","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37195.31,"maximum":70090.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53140.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61467.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58840.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55535.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37195.31},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44588.72},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":70090.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46583.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67971.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60203.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51321.15},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58518.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","code_information":[{"code":"428","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":61375.37,"maximum":115655.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":87686.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101426.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97091.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91638.6},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61375.37},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73575.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":115655.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76867.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112158.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99340.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84684.19},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96559.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","code_information":[{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9315.48,"maximum":17553.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13308.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15394.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14736.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13908.79},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9315.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11167.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17553.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11666.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17023.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15077.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12853.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14655.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract With Cc","code_information":[{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11947.56,"maximum":22513.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17069.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19744.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18900.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17838.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11947.56},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14322.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22513.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14963.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21833.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19338.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16484.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18796.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16335.82,"10th_percentile":16335.82,"90th_percentile":16335.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Or Infection Without Cc/Mcc","code_information":[{"code":"458","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45552.27,"maximum":85838.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65080.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75277.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72060.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68013.38},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45552.27},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54606.82},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":85838.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57050.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83243.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73729.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62851.87},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71665.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","code_information":[{"code":"468","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29999.92,"maximum":56531.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42860.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49576.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47457.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44792.4},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29999.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35963.08},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":56531.47},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37572.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54822.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48557.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41393.12},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47197.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"476","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12884.24,"maximum":24278.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18407.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21291.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20382.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19237.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12884.24},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15445.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24278.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16136.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23544.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20854.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17777.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20270.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Mcc","code_information":[{"code":"485","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35230.25,"maximum":66387.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50333.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58220.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55732.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52601.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35230.25},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42233.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66387.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44122.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64380.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57022.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48609.81},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55426.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","code_information":[{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39581.77,"maximum":74587.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56550.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65411.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62615.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59098.91},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39581.77},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47449.54},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74587.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49572.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72332.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64066.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54613.92},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62272.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Mcc","code_information":[{"code":"503","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30470.44,"maximum":57418.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43532.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50354.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48202.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45494.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30470.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36527.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":57418.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38161.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55682.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49318.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42042.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47938.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","code_information":[{"code":"512","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18072.0,"maximum":34054.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25819.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29865.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28588.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26983.02},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18072.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21664.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34054.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22633.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33025.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29250.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24935.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28432.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","code_information":[{"code":"520","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16308.91,"maximum":30732.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23300.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26951.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25799.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24350.57},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16308.91},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19550.67},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30732.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20425.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29803.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26397.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22502.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25658.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","code_information":[{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7863.52,"maximum":14817.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11234.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12994.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12439.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11740.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7863.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9426.57},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14817.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9848.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14369.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12727.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10849.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12371.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Cc","code_information":[{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12591.67,"maximum":23727.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17989.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20808.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19919.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18800.42},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12591.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15094.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23727.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15769.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23010.33},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20380.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17373.66},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19810.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone Diseases And Arthropathies Without Mcc","code_information":[{"code":"554","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9062.2,"maximum":17076.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12947.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14975.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14335.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13530.63},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9062.2},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10863.52},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17076.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11349.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16560.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14667.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12503.8},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14257.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","code_information":[{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15554.54,"maximum":29310.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22222.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25704.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24606.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23224.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15554.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18646.36},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29310.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19480.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28424.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25176.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21461.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24471.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"573","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":71521.63,"maximum":134774.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102182.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118193.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113142.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106787.82},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71521.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85738.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":134774.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89574.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130700.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115763.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98683.74},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112522.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","code_information":[{"code":"581","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15754.32,"maximum":29687.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22508.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26034.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24922.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23522.53},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15754.32},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18885.85},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29687.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19730.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28789.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25499.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21737.42},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24785.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders With Mcc","code_information":[{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23151.68,"maximum":43626.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33076.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38259.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36624.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34567.41},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23151.68},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27753.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43626.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28995.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42307.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37472.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31944.1},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36423.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cellulitis Without Mcc","code_information":[{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9507.62,"maximum":17916.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13583.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15711.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15040.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14195.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9507.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11397.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17916.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11907.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17374.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15388.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13118.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14958.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":12391.23,"10th_percentile":12391.23,"90th_percentile":12391.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11589.56,"10th_percentile":8649.0,"90th_percentile":11684.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"1 through 10","median_amount":3310.84,"10th_percentile":3310.84,"90th_percentile":3310.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":9665.06,"10th_percentile":9665.06,"90th_percentile":9665.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"1 through 10","median_amount":8091.39,"10th_percentile":8091.39,"90th_percentile":8091.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":7237.09,"10th_percentile":7237.09,"90th_percentile":7237.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":1039.0,"10th_percentile":1039.0,"90th_percentile":1452.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":2018.28,"10th_percentile":2018.28,"90th_percentile":2018.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"617","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20418.07,"maximum":38475.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29171.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33742.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32300.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30485.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20418.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24476.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38475.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25571.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37312.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33048.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28172.33},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32123.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19144.18,"10th_percentile":19144.18,"90th_percentile":19144.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":29792.41,"10th_percentile":29792.41,"90th_percentile":29792.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":34845.66,"10th_percentile":34845.66,"90th_percentile":34845.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":14258.83,"10th_percentile":14258.83,"90th_percentile":14258.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","code_information":[{"code":"625","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32970.43,"maximum":62129.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47104.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54485.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52157.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49227.63},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32970.43},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39524.05},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62129.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41292.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60251.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53365.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45491.77},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51871.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes Without Cc/Mcc","code_information":[{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6781.64,"maximum":12779.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9688.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11207.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10728.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10125.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6781.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8129.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12779.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8493.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12392.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10976.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9357.14},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10669.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis Without Mcc","code_information":[{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40456.22,"maximum":76235.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57799.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66856.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63999.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60404.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40456.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48497.8},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":76235.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50667.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73930.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65481.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55820.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63648.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","code_information":[{"code":"659","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27739.01,"maximum":52271.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39630.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45840.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43881.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41416.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27739.01},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33252.76},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":52271.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34740.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50690.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44897.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38273.58},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43640.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy Without Cc/Mcc","code_information":[{"code":"667","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12076.39,"maximum":22756.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17253.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19956.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19104.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18031.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12076.39},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14476.84},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22756.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15124.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22068.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19546.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16662.69},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18999.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","code_information":[{"code":"675","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17919.16,"maximum":33766.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25600.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29612.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28346.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26754.82},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17919.16},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21481.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33766.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22442.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32745.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29003.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24724.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28191.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections Without Mcc","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8837.31,"maximum":16652.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12625.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14604.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13980.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13194.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8837.31},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10593.93},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16652.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11067.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16149.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14303.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12193.5},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13903.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":291.78,"10th_percentile":291.78,"90th_percentile":291.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9033.86,"10th_percentile":9033.86,"90th_percentile":9033.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":11882.35,"10th_percentile":11882.35,"90th_percentile":21083.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":10384.22,"10th_percentile":10384.22,"90th_percentile":10384.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","code_information":[{"code":"700","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7531.64,"maximum":14192.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10760.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12446.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11914.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11245.37},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7531.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9028.72},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14192.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9432.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13763.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12190.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10391.96},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11849.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy Without Cc/Mcc","code_information":[{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11543.64,"maximum":21752.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16492.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19076.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18261.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17235.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11543.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13838.19},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21752.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14457.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21095.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18684.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15927.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18161.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Benign Prostatic Hypertrophy With Mcc","code_information":[{"code":"725","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12775.07,"maximum":24073.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18251.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21111.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20209.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19074.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12775.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15314.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24073.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15999.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23345.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20677.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17626.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20098.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","code_information":[{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39022.82,"maximum":73534.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55751.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64487.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61731.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58264.35},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39022.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46779.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73534.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48872.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71311.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63161.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53842.69},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61393.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","code_information":[{"code":"744","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22370.02,"maximum":42153.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31959.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36967.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35387.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33400.33},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22370.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26816.57},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42153.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28016.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40879.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36207.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30865.59},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35194.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System With Cc","code_information":[{"code":"755","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11875.51,"maximum":22378.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16966.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18786.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17731.14},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11875.51},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14236.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22378.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14873.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21701.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19221.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16385.53},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18683.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses With O.R. Procedures","code_information":[{"code":"769","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18447.55,"maximum":34762.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26355.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30485.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29182.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27543.74},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18447.55},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22114.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34762.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23103.98},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33711.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29858.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25453.46},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29022.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Cc","code_information":[{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12192.11,"maximum":22974.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17418.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20148.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19287.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18203.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12192.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14615.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22974.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15269.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22280.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19733.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16822.36},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19181.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":26232.41,"10th_percentile":26232.41,"90th_percentile":26232.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12545.0,"10th_percentile":12545.0,"90th_percentile":12545.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":12344.79,"10th_percentile":12344.79,"90th_percentile":12344.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Normal Newborn","code_information":[{"code":"795","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":2181.22,"maximum":4110.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":3116.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3604.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3450.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":3256.74},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2181.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2614.78},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":4110.26},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2731.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3986.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3530.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3009.59},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":3431.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2309.43,"10th_percentile":2309.43,"90th_percentile":3308.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":2543.5,"10th_percentile":2317.39,"90th_percentile":3348.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"11","median_amount":2309.43,"10th_percentile":1167.55,"90th_percentile":2608.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2424.9,"10th_percentile":2424.9,"90th_percentile":2424.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4650.91,"10th_percentile":4650.91,"90th_percentile":4650.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2309.43,"10th_percentile":2309.43,"90th_percentile":3308.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2309.43,"10th_percentile":2309.43,"90th_percentile":2309.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2424.9,"10th_percentile":2424.9,"90th_percentile":2498.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":2684.95,"10th_percentile":2684.95,"90th_percentile":3085.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2309.43,"10th_percentile":2309.43,"90th_percentile":2309.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2669.67,"10th_percentile":2669.67,"90th_percentile":2669.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"21","median_amount":2266.0,"10th_percentile":1133.0,"90th_percentile":3399.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2309.43,"10th_percentile":1899.44,"90th_percentile":2433.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","code_information":[{"code":"803","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20293.61,"maximum":38241.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28993.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33536.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32103.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30300.07},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20293.61},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24327.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38241.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25416.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37085.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32846.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28000.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31927.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders With Mcc","code_information":[{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15330.74,"maximum":28889.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21902.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25334.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24252.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22890.09},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15330.74},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18378.07},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28889.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19200.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28015.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24813.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21152.97},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24119.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"819","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9387.53,"maximum":17689.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13411.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15513.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14850.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14016.37},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9387.53},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11253.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17689.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11757.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17155.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15194.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12952.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14769.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Cc","code_information":[{"code":"827","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25231.37,"maximum":47545.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36047.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41696.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39914.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37672.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25231.37},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30246.67},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47545.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31600.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46108.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40838.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34813.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39695.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Cc","code_information":[{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22770.68,"maximum":42908.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32532.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37629.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36021.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33998.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22770.68},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27296.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42908.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28518.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41611.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36856.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31418.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35824.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","code_information":[{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21777.23,"maximum":41036.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31112.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35988.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34450.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32515.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21777.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26105.95},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41036.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27274.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39796.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35248.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30047.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34261.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","code_information":[{"code":"853","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":53914.7,"maximum":101596.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77027.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89097.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85289.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80499.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53914.7},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64631.46},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":101596.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67523.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98525.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87265.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74390.13},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84822.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":74554.92,"10th_percentile":74554.92,"90th_percentile":74554.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":19230.3,"10th_percentile":19230.3,"90th_percentile":19230.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fever And Inflammatory Conditions","code_information":[{"code":"864","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9691.02,"maximum":18261.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13845.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16015.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15330.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14469.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9691.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11617.33},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18261.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12137.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17709.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15685.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13371.43},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15246.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7199.29,"10th_percentile":7199.29,"90th_percentile":7199.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","code_information":[{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11171.37,"maximum":21051.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15960.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18461.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17672.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16679.79},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11171.37},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13391.93},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21051.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13991.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20414.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18081.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15413.97},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17575.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13179.91,"10th_percentile":13179.91,"90th_percentile":13179.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":34281.14,"10th_percentile":34281.14,"90th_percentile":34281.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9530.28,"10th_percentile":9530.28,"90th_percentile":9530.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":16051.1,"10th_percentile":11773.46,"90th_percentile":29149.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":12057.05,"10th_percentile":11180.94,"90th_percentile":14168.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11154.5,"10th_percentile":11154.5,"90th_percentile":11154.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9076.46,"10th_percentile":9076.46,"90th_percentile":9076.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Behavioral And Developmental Disorders","code_information":[{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22656.05,"maximum":42692.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32368.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37440.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35840.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33827.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22656.05},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27159.45},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42692.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28374.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41402.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36670.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31260.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35644.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries Without Cc/Mcc","code_information":[{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12768.52,"maximum":24060.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18242.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21100.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20198.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19064.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12768.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15306.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24060.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15991.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23333.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20666.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17617.68},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20088.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Injury Without Mcc","code_information":[{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9667.0,"maximum":18216.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13811.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15975.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15292.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14433.65},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9667.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11588.54},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18216.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12107.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17665.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15646.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13338.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15208.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","code_information":[{"code":"922","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19098.2,"maximum":35988.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27285.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31560.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30212.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28515.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19098.2},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22894.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35988.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23918.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34900.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30911.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26351.21},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30046.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","code_information":[{"code":"939","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39612.33,"maximum":74644.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56593.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65461.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62664.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59144.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39612.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47486.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74644.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49611.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72388.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64115.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54656.1},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62320.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":3250.92,"10th_percentile":3250.92,"90th_percentile":3250.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","code_information":[{"code":"003","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":231715.51,"maximum":436641.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":331049.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":382923.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":366559.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":345970.76},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":231715.51},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":277774.19},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":436641.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":290203.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":423442.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":375049.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":319715.19},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":364550.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","code_information":[{"code":"012","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46026.07,"maximum":86730.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65756.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76060.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72810.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68720.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46026.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55174.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86730.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57643.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84109.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74496.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63505.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72411.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","code_information":[{"code":"021","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":57792.41,"maximum":108903.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82567.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95505.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91423.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86288.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57792.41},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69279.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":108903.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72380.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105611.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93541.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79740.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90922.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures With Cc Or Spinal Neurostimulators","code_information":[{"code":"029","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37244.44,"maximum":70182.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53210.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61548.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58918.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55609.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37244.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44647.61},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":70182.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46645.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68061.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60282.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51388.93},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58595.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Mcc","code_information":[{"code":"037","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35939.86,"maximum":67724.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51346.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59392.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56854.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53661.23},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35939.86},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43083.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":67724.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45011.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65677.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58171.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49588.9},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56542.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms With Mcc","code_information":[{"code":"054","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16669.17,"maximum":31411.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23815.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27546.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26369.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24888.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16669.17},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19982.54},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31411.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20876.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30461.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26980.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22999.69},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26225.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","code_information":[{"code":"062","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19183.35,"maximum":36148.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27407.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31701.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30346.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28642.36},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19183.35},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22996.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36148.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24025.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35056.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31049.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26468.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30180.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders With Mcc","code_information":[{"code":"070","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18174.62,"maximum":34248.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25965.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30034.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28751.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27136.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18174.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21787.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34248.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22762.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33212.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29417.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25076.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28593.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nontraumatic Stupor And Coma Without Mcc","code_information":[{"code":"081","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9777.27,"maximum":18424.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13968.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16157.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15467.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14598.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9777.27},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11720.72},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18424.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12245.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17867.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15825.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.42},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15382.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Cc","code_information":[{"code":"089","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11993.42,"maximum":22600.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17134.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19819.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18972.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17907.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11993.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14377.38},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22600.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15020.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21917.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19412.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16548.21},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18868.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","code_information":[{"code":"097","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39430.02,"maximum":74301.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56333.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65160.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62375.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58872.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39430.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47267.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74301.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49382.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72055.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63820.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54404.54},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62033.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures Without Cc/Mcc","code_information":[{"code":"114","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14770.7,"maximum":27833.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21102.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24409.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23366.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22053.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14770.7},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17706.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27833.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18499.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26992.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23907.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20380.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23238.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye Without Mcc","code_information":[{"code":"125","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8382.07,"maximum":15795.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11975.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13851.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13259.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12515.14},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8382.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10048.2},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15795.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10497.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15317.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13567.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11565.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13187.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures Without Cc/Mcc","code_information":[{"code":"142","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17427.9,"maximum":32840.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24899.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28800.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27569.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26021.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17427.9},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20892.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32840.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21826.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31848.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28208.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24046.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27418.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis With Mcc","code_information":[{"code":"150","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14535.99,"maximum":27391.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20767.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24021.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22995.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21703.45},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14535.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17425.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27391.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18205.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26563.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23527.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20056.38},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22868.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Cc","code_information":[{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9932.29,"maximum":18716.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14190.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16413.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15712.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14829.74},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9932.29},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11906.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18716.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12439.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18150.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16076.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13704.32},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15626.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","code_information":[{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32493.36,"maximum":61230.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":46422.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53697.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51402.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48515.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32493.36},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38952.15},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":61230.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40695.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59379.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52592.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44833.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51120.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms Without Cc/Mcc","code_information":[{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8229.23,"maximum":15507.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11757.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13599.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13018.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12286.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8229.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9864.98},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15507.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10306.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15038.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13319.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11354.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12946.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Mcc","code_information":[{"code":"190","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12092.76,"maximum":22787.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17276.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19984.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19129.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18055.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12092.76},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14496.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22787.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15145.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22098.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19573.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16685.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19025.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":3295.59,"10th_percentile":3295.59,"90th_percentile":3295.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":26286.64,"10th_percentile":26286.64,"90th_percentile":26286.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13255.59,"10th_percentile":12749.06,"90th_percentile":13900.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease Without Cc/Mcc","code_information":[{"code":"198","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7818.76,"maximum":14733.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11170.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12920.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12368.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11674.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7818.76},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9372.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14733.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9792.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14288.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12655.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10788.12},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12300.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses Without Mcc","code_information":[{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10273.99,"maximum":19360.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14678.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16978.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16252.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15339.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10273.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12316.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19360.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12867.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18774.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16629.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14175.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16163.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","code_information":[{"code":"217","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":71782.55,"maximum":135266.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102554.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118624.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113555.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107177.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71782.55},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86050.95},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":135266.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89901.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131177.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116185.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99043.74},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112933.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca Without Mcc","code_information":[{"code":"232","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":66185.4,"maximum":124718.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":94558.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109375.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104701.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98820.38},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66185.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79341.25},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":124718.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82891.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120948.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107126.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91320.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104127.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Mcc","code_information":[{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34855.8,"maximum":65681.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49798.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57601.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55139.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52042.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34855.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41784.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65681.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43653.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63696.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56416.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48093.15},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54837.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures Without Cc/Mcc","code_information":[{"code":"254","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19450.82,"maximum":36652.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27789.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32143.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30769.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29041.71},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19450.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23317.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36652.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24360.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35544.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31482.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26837.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30601.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","code_information":[{"code":"262","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17793.62,"maximum":33530.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25421.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29405.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28148.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26567.37},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17793.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21330.5},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33530.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22284.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32516.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28800.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24551.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27994.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Mcc","code_information":[{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":57601.37,"maximum":108543.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":82294.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95189.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91121.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86003.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57601.37},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69050.94},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":108543.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72140.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105262.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93232.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79476.91},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90622.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","code_information":[{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":60766.21,"maximum":114507.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86816.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":100419.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96128.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90729.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60766.21},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72844.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":114507.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76104.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111045.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98354.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83843.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95601.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","code_information":[{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24157.14,"maximum":45521.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34513.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39921.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38215.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36068.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24157.14},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28958.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45521.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30254.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44145.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39100.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33331.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38005.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Mcc","code_information":[{"code":"296","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17051.26,"maximum":32131.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24360.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28178.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26974.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25458.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17051.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20440.59},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32131.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21355.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31159.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27598.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23526.9},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26826.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertension With Mcc","code_information":[{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12991.23,"maximum":24480.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18560.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21468.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20551.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19397.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12991.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15573.53},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24480.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16270.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23740.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21027.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17924.97},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20438.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","code_information":[{"code":"004","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":151215.73,"maximum":284949.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":216040.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":249893.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":239213.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":225777.82},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":151215.73},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":181273.27},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":284949.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":189384.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":276335.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":244754.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":208643.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":237902.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","code_information":[{"code":"013","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31460.61,"maximum":59283.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44947.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51990.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49768.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46973.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31460.61},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37714.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59283.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39401.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57491.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50921.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43408.55},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49495.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","code_information":[{"code":"022","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34687.68,"maximum":65365.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49557.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57323.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54873.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51791.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34687.68},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41582.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65365.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43443.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63389.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56144.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47861.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54572.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures Without Cc/Mcc","code_information":[{"code":"030","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23965.0,"maximum":45159.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34238.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39603.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37911.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35781.76},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23965.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28728.58},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45159.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30014.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43794.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38789.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33066.3},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37703.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Cc","code_information":[{"code":"038","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17713.92,"maximum":33379.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25307.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29273.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28022.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26448.38},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17713.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21234.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33379.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22185.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32370.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28671.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24441.22},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27868.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms Without Mcc","code_information":[{"code":"055","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11130.97,"maximum":20975.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15902.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18394.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17608.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16619.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11130.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13343.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20975.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13940.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20341.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18016.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15358.23},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17511.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","code_information":[{"code":"063","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15325.28,"maximum":28878.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21895.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25325.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24243.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22881.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15325.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18371.53},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28878.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19193.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28005.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24805.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21145.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24110.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders With Cc","code_information":[{"code":"071","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11200.84,"maximum":21106.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16002.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18510.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17719.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16723.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11200.84},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13427.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21106.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14028.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20468.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18129.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15454.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17621.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour With Mcc","code_information":[{"code":"082","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24951.9,"maximum":47019.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35648.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41234.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39472.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37255.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24951.9},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29911.65},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47019.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31250.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45597.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40386.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34427.99},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39255.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6988.51,"10th_percentile":6988.51,"90th_percentile":6988.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion Without Cc/Mcc","code_information":[{"code":"090","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8986.87,"maximum":16934.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12839.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14851.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14216.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13418.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8986.87},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10773.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16934.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11255.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16422.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14545.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12399.86},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14138.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","code_information":[{"code":"098","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25053.42,"maximum":47210.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35793.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41402.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39632.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37406.87},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25053.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30033.36},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47210.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31377.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45783.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40550.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34568.08},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39415.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extraocular Procedures Except Orbit","code_information":[{"code":"115","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16756.5,"maximum":31575.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23939.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27691.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26507.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25018.87},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16756.5},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20087.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31575.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20986.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30621.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27121.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23120.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26362.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures With Cc/Mcc","code_information":[{"code":"135","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23689.89,"maximum":44640.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33845.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39148.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37475.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35371.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23689.89},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28398.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44640.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29669.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43291.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38343.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32686.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37270.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Mcc","code_information":[{"code":"143","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40901.63,"maximum":77074.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58435.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67592.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64703.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61069.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40901.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49031.75},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":77074.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51225.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74744.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66202.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56435.04},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64349.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis Without Mcc","code_information":[{"code":"151","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8013.08,"maximum":15099.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11448.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13242.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12676.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11964.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8013.08},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9605.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15099.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10035.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14643.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12969.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11056.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12606.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases Without Cc/Mcc","code_information":[{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7734.69,"maximum":14575.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11050.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12782.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12235.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11548.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7734.69},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9272.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14575.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9687.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14134.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12519.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10672.14},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12168.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","code_information":[{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14995.59,"maximum":28257.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21424.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24781.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23722.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22389.68},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14995.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17976.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28257.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18780.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27403.32},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24271.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20690.54},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23592.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":14034.98,"10th_percentile":14034.98,"90th_percentile":14034.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":21601.16,"10th_percentile":21601.16,"90th_percentile":21601.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13021.89,"10th_percentile":13021.89,"90th_percentile":13021.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma With Mcc","code_information":[{"code":"183","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16701.92,"maximum":31472.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23861.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27600.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26421.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24937.37},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16701.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20021.8},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31472.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20917.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30521.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27033.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23044.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26276.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Cc","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9203.03,"maximum":17342.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13148.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15208.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14558.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13740.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9203.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11032.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17342.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11526.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16817.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14895.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12698.11},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14478.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6250.69,"10th_percentile":6250.69,"90th_percentile":6250.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13160.79,"10th_percentile":13160.79,"90th_percentile":13160.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax With Mcc","code_information":[{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19258.68,"maximum":36290.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27514.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31826.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30466.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28754.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19258.68},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23086.78},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36290.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24119.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35193.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31171.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26572.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30299.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","code_information":[{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":70247.62,"maximum":132373.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":100362.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116088.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":111127.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104885.61},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70247.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84210.92},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":132373.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87979.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128372.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113701.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96925.89},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110518.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization Without Cc/Mcc","code_information":[{"code":"218","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":71782.55,"maximum":135266.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":102554.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118624.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":113555.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107177.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71782.55},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86050.95},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":135266.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89901.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131177.24},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":116185.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99043.74},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":112933.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","code_information":[{"code":"233","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":83462.65,"maximum":157275.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":119242.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137927.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":132032.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124616.76},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83462.65},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100052.73},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":157275.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104529.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152521.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135090.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115159.65},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131308.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Cc","code_information":[{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23263.04,"maximum":43836.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33235.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38443.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36800.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34733.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23263.04},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27887.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43836.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29134.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42511.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37653.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32097.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36598.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","code_information":[{"code":"255","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29447.52,"maximum":55490.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42071.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48663.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46584.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43967.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29447.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35300.87},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":55490.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36880.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53813.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47663.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40630.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46328.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vein Ligation And Stripping","code_information":[{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33377.64,"maximum":62896.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47686.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55158.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52801.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49835.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33377.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40012.19},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62896.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41802.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60995.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54024.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46053.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52511.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Cc","code_information":[{"code":"271","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38824.13,"maximum":73159.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55467.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64159.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61417.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57967.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38824.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46541.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73159.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48623.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70948.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62839.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53568.55},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61080.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","code_information":[{"code":"279","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39371.07,"maximum":74190.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56249.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65063.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62282.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58784.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39371.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47196.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74190.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49308.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71947.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63725.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54323.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61941.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","code_information":[{"code":"287","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11682.28,"maximum":22013.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16690.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19305.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18480.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17442.63},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11682.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14004.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22013.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14631.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21348.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18908.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16118.92},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18379.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Cc","code_information":[{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6921.38,"maximum":13042.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9888.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11437.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10949.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10334.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6921.38},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8297.16},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13042.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8668.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12648.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11202.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10889.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertension Without Mcc","code_information":[{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8243.43,"maximum":15533.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11777.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13622.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13040.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12308.13},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8243.43},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9881.99},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15533.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10324.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15064.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13342.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11374.07},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12969.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8350.29,"10th_percentile":8350.29,"90th_percentile":8350.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Liver Transplant Without Mcc","code_information":[{"code":"006","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50622.13,"maximum":95391.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72323.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83656.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80080.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75583.1},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50622.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60684.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":95391.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63399.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92508.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81935.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69847.13},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79642.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Autologous Bone Marrow Transplant With Cc/Mcc","code_information":[{"code":"016","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":64734.53,"maximum":121984.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92485.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":106977.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102405.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96654.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64734.53},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77601.98},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":121984.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81074.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118297.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104777.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89319.07},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101844.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","code_information":[{"code":"024","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42706.21,"maximum":80475.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":61013.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70574.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67558.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63763.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42706.21},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51195.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":80475.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53485.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78042.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69123.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58924.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67188.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Cc","code_information":[{"code":"032","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23264.13,"maximum":43838.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33237.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38445.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36802.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34735.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23264.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27888.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43838.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29136.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42513.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37654.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32099.25},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36600.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","code_information":[{"code":"040","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42152.72,"maximum":79432.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60223.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69659.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66682.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62937.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42152.72},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50531.52},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":79432.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52792.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77030.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68227.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58161.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66317.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders Without Mcc","code_information":[{"code":"057","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14144.07,"maximum":26652.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20207.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23373.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22375.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21118.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14144.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16955.52},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26652.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17714.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25847.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22893.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19515.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22252.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","code_information":[{"code":"065","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11029.45,"maximum":20783.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15757.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18226.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17447.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16467.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11029.45},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13221.8},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20783.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13813.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20155.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17852.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15218.15},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17352.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11065.78,"10th_percentile":11065.78,"90th_percentile":11065.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":34.78,"10th_percentile":34.78,"90th_percentile":34.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":9244.22,"10th_percentile":9244.22,"90th_percentile":16343.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":8388.8,"10th_percentile":7871.27,"90th_percentile":11251.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders With Mcc","code_information":[{"code":"073","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17514.14,"maximum":33003.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25022.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28943.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27706.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26150.09},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17514.14},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20995.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33003.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21934.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32005.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28347.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24165.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27554.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":5086.82,"10th_percentile":5086.82,"90th_percentile":5086.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","code_information":[{"code":"084","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10434.47,"maximum":19662.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14907.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17243.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16506.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15579.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10434.47},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12508.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19662.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13068.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19068.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16888.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14397.22},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16416.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Cc","code_information":[{"code":"092","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11168.09,"maximum":21045.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15955.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18455.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17667.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16674.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11168.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13388.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21045.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13987.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20408.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18076.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15409.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17570.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Seizures With Mcc","code_information":[{"code":"100","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21144.05,"maximum":39843.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30208.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34941.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33448.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31569.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21144.05},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25346.9},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39843.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26481.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38639.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34223.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29174.02},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33265.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":11495.71,"10th_percentile":11495.71,"90th_percentile":11495.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures Without Cc/Mcc","code_information":[{"code":"117","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11843.85,"maximum":22318.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16921.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19572.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18736.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17683.87},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11843.85},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14198.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22318.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14833.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21643.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19170.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16341.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18633.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures With Cc/Mcc","code_information":[{"code":"137","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16301.26,"maximum":30717.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23289.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26938.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25787.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24339.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16301.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19541.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30717.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20415.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29789.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26384.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22492.07},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25646.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","code_information":[{"code":"145","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13125.51,"maximum":24733.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18752.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21690.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20763.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19597.49},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13125.51},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15734.5},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24733.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16438.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23985.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21244.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18110.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20649.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri Without Mcc","code_information":[{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8058.93,"maximum":15186.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11513.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13317.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12748.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12032.66},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8058.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9660.82},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15186.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10093.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14727.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13043.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11119.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12678.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Cc","code_information":[{"code":"164","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27554.51,"maximum":51923.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39366.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45535.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43589.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41141.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27554.51},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33031.59},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51923.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34509.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50353.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44599.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38019.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43350.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations With Mcc","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17060.0,"maximum":32147.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24373.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28192.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26987.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25472.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17060.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20451.05},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32147.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21366.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31175.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27612.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23538.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26839.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":24672.58,"10th_percentile":24672.58,"90th_percentile":24672.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8682.28,"10th_percentile":8682.28,"90th_percentile":8682.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":12548.06,"10th_percentile":12548.06,"90th_percentile":12548.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma Without Cc/Mcc","code_information":[{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8586.22,"maximum":16179.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12267.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14189.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13582.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12819.95},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8586.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10292.93},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16179.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10753.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15690.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13897.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11847.05},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13508.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy With Mcc","code_information":[{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14349.3,"maximum":27039.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20500.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23713.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22699.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21424.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14349.3},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17201.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27039.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17971.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26222.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23225.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19798.81},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22575.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20545.82,"10th_percentile":20545.82,"90th_percentile":20545.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14511.76,"10th_percentile":14511.76,"90th_percentile":14511.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13893.97,"10th_percentile":13893.97,"90th_percentile":13893.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":14890.49,"10th_percentile":4929.74,"90th_percentile":21506.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11181.53,"10th_percentile":11181.53,"90th_percentile":11181.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":8157.01,"10th_percentile":7071.27,"90th_percentile":12521.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":17170.75,"10th_percentile":17170.75,"90th_percentile":17170.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax Without Cc/Mcc","code_information":[{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7806.75,"maximum":14710.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11153.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12901.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12349.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11656.13},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7806.75},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9358.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14710.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9777.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14266.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12635.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10771.55},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12282.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complex Aortic Arch Procedures","code_information":[{"code":"209","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":123567.34,"maximum":232848.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":176539.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":204202.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":195475.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":184496.44},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123567.34},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148129.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":232848.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154757.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":225810.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":200003.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":170495.08},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194404.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","code_information":[{"code":"220","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":58218.18,"maximum":109705.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83175.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96209.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92097.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86924.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58218.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69790.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":109705.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72913.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106389.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94230.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80327.97},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91592.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization With Mcc","code_information":[{"code":"235","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":64067.51,"maximum":120728.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91532.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105875.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101350.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95658.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64067.51},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76802.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":120728.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80239.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117078.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103698.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88398.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100795.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Generator Procedures","code_information":[{"code":"245","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49807.72,"maximum":93857.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71159.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82310.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78792.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74367.12},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49807.72},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59708.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":93857.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62379.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91019.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80617.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68723.43},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78360.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders Without Cc/Mcc","code_information":[{"code":"257","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11923.55,"maximum":22468.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17035.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19704.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18862.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17802.86},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11923.55},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14293.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22468.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14933.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21789.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19299.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16451.81},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18758.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Lead Procedures","code_information":[{"code":"265","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39499.89,"maximum":74433.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56433.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65275.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62486.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58976.66},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39499.89},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47351.38},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74433.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49470.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72183.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63933.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54500.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62143.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures With Mcc","code_information":[{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45038.08,"maximum":84869.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64345.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74428.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71247.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67245.65},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45038.08},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53990.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":84869.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56406.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82303.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72897.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62142.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70856.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Cc","code_information":[{"code":"281","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10033.81,"maximum":18907.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14335.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16581.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15872.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14981.33},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10033.81},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12028.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18907.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12566.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18336.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16240.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13844.4},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15785.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":7373.32,"10th_percentile":7373.32,"90th_percentile":7373.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis With Cc","code_information":[{"code":"289","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18634.23,"maximum":35114.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26622.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30794.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29478.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27822.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18634.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22338.2},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35114.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23337.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34052.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30160.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25711.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29316.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Mcc","code_information":[{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17824.19,"maximum":33587.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25465.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29455.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28196.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26613.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17824.19},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21367.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33587.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22323.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32572.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28849.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24593.36},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28042.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":23081.5,"10th_percentile":23081.5,"90th_percentile":23081.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5907.99,"10th_percentile":5907.99,"90th_percentile":5907.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Congenital And Valvular Disorders Without Mcc","code_information":[{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9969.4,"maximum":18786.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14243.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16475.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15770.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14885.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9969.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11951.05},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18786.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12485.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18218.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16136.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13755.53},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15684.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas, Islet Cell And Kidney Transplant","code_information":[{"code":"008","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":61185.42,"maximum":115297.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":87414.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101112.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96791.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":91354.98},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61185.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73347.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":115297.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76629.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":111811.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99033.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84422.09},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96260.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","code_information":[{"code":"018","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":471426.63,"maximum":888350.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":673522.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":779060.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":745766.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":703879.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":471426.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":565133.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":888350.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":590421.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":861496.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":763040.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":650462.52},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":741679.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures With Cc","code_information":[{"code":"026","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33943.14,"maximum":63962.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48494.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56093.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53695.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50679.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33943.14},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40690.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":63962.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42510.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62028.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54939.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46833.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53401.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Mcc","code_information":[{"code":"034","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42256.43,"maximum":79627.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60371.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69831.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66846.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63092.41},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42256.43},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50655.85},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":79627.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52922.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77220.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68395.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58304.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66480.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","code_information":[{"code":"042","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18861.3,"maximum":35542.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26946.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31169.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29837.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28161.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18861.3},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22610.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35542.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23622.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34467.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30528.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26024.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29673.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Cc","code_information":[{"code":"059","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13546.91,"maximum":25527.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19354.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21430.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20226.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13546.91},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16239.66},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25527.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16966.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24755.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21926.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18691.68},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21312.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Precerebral Occlusion Without Infarction With Mcc","code_information":[{"code":"067","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16033.8,"maximum":30213.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22907.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26496.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25364.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23939.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16033.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19220.88},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30213.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20080.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29300.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25951.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22123.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25225.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Meningitis With Cc/Mcc","code_information":[{"code":"075","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20933.35,"maximum":39446.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29907.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34593.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33115.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31255.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20933.35},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25094.32},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39446.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26217.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38254.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33882.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28883.3},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32933.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Cc","code_information":[{"code":"086","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14221.58,"maximum":26798.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20318.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23502.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22497.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21234.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14221.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17048.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26798.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17811.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25988.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23018.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19622.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22374.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Mcc","code_information":[{"code":"094","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38421.29,"maximum":72400.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54892.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63493.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60780.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57366.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38421.29},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46058.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":72400.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48119.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70212.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62187.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53012.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60446.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches With Mcc","code_information":[{"code":"102","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12236.87,"maximum":23059.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17482.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20222.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19357.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18270.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12236.87},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14669.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23059.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15325.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22361.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19806.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16884.12},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19251.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections Without Cc/Mcc","code_information":[{"code":"122","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8578.58,"maximum":16165.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12256.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14176.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13570.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12808.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8578.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10283.76},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16165.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10743.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15676.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13885.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11836.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13496.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Salivary Gland Procedures","code_information":[{"code":"139","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13490.14,"maximum":25420.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19273.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22293.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21340.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20141.91},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.14},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16171.61},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25420.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16895.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24652.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21834.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18613.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21223.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Cc","code_information":[{"code":"147","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13880.97,"maximum":26157.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19831.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22939.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21958.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20725.45},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13880.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16640.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26157.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17384.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25366.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22467.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19152.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21838.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","code_information":[{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10005.43,"maximum":18854.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14294.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16534.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15827.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14938.95},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10005.43},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11994.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18854.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12530.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18284.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16194.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13805.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15741.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Mcc","code_information":[{"code":"166","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40804.47,"maximum":76891.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58296.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67431.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64550.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60924.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40804.47},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48915.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":76891.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51104.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74567.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66045.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56300.98},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64196.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations Without Cc/Mcc","code_information":[{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8242.34,"maximum":15531.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11775.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13620.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13038.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12306.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8242.34},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9880.69},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15531.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10322.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15062.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13340.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11372.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12967.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":11273.35,"10th_percentile":11273.35,"90th_percentile":11273.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Cc","code_information":[{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10798.0,"maximum":20347.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15426.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17844.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17081.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16122.33},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10798.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12944.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20347.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13523.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19732.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17477.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14898.81},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16988.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","code_information":[{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6861.33,"maximum":12929.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9802.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11338.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10854.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10244.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6861.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8225.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12929.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8593.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12538.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11105.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9467.1},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10794.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5108.0,"10th_percentile":5108.0,"90th_percentile":5108.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6135.8,"10th_percentile":6135.8,"90th_percentile":6135.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":2766.16,"10th_percentile":2766.16,"90th_percentile":2766.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bronchitis And Asthma Without Cc/Mcc","code_information":[{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7314.39,"maximum":13783.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10449.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12087.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11570.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10921.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7314.39},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8768.29},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13783.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9160.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13366.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11838.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10092.21},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11507.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Abdominal Aorta With Iliac Branch Procedures","code_information":[{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62302.23,"maximum":117401.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89010.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102958.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98558.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93022.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62302.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74686.2},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":117401.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78028.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113852.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100840.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85963.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98018.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures With Mcc","code_information":[{"code":"228","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":54010.77,"maximum":101777.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77164.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89256.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85441.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80642.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54010.77},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64746.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":101777.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67643.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98700.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87420.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74522.69},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84973.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","code_information":[{"code":"239","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":53730.2,"maximum":101248.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76763.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88792.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84997.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80223.71},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53730.2},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64410.29},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":101248.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67292.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98187.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86966.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74135.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84531.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","code_information":[{"code":"251","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16315.46,"maximum":30744.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23309.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26962.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25810.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24360.35},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16315.46},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19558.52},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30744.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20433.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29815.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26407.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22511.65},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25668.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement Without Mcc","code_information":[{"code":"259","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22075.27,"maximum":41598.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31538.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36480.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34921.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32960.23},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22075.27},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26463.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41598.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27647.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40340.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35730.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30458.89},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34730.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","code_information":[{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":51973.65,"maximum":97938.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74254.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":85889.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82219.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77601.04},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51973.65},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62304.59},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":97938.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65092.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94977.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84123.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71711.93},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81768.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","code_information":[{"code":"275","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":77842.58,"maximum":146685.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111212.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128639.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123142.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116225.52},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77842.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93315.54},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":146685.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97491.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142251.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125994.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107405.22},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122467.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Mcc","code_information":[{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21624.39,"maximum":40748.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30894.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35735.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34208.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32287.04},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21624.39},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25922.73},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40748.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27082.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39516.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35000.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29836.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34020.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock With Mcc","code_information":[{"code":"291","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14015.24,"maximum":26410.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20023.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23161.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22171.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20925.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14015.24},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16801.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26410.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17552.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25611.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22684.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19337.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22049.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":2580.74,"10th_percentile":2580.74,"90th_percentile":2580.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20350.97,"10th_percentile":20350.97,"90th_percentile":20350.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13578.61,"10th_percentile":13578.61,"90th_percentile":13578.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5413.34,"10th_percentile":5413.34,"90th_percentile":27584.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"1 through 10","median_amount":9767.39,"10th_percentile":9767.39,"90th_percentile":9767.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":12765.24,"10th_percentile":8517.95,"90th_percentile":18992.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":8674.38,"10th_percentile":3708.22,"90th_percentile":11881.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders Without Cc/Mcc","code_information":[{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7856.96,"maximum":14805.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11225.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12984.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12429.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11731.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7856.96},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9418.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14805.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9840.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14358.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12717.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10840.84},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12361.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Cc","code_information":[{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8031.64,"maximum":15134.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11474.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13272.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12705.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11991.91},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8031.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9628.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15134.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10058.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12999.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11081.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12635.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":16704.43,"10th_percentile":16704.43,"90th_percentile":16704.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","code_information":[{"code":"317","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":72996.52,"maximum":137553.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104289.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120631.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":115475.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108989.95},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72996.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87506.23},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":137553.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91421.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133395.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118150.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100718.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114842.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy Without Intraluminal Device","code_information":[{"code":"325","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35047.94,"maximum":66043.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50072.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57918.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55443.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52329.52},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35047.94},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42014.5},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66043.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43894.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64047.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56727.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48358.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55139.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection With Cc","code_information":[{"code":"333","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25569.8,"maximum":48183.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36531.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42255.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40449.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38177.86},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25569.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30652.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":48183.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32023.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46726.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41386.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35280.56},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40228.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Mcc","code_information":[{"code":"347","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25061.07,"maximum":47224.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35804.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41414.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39645.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37418.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25061.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30042.52},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47224.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31386.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45797.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40563.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34578.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39427.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","code_information":[{"code":"355","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14683.37,"maximum":27669.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20977.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24265.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23228.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21923.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14683.37},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17602.02},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27669.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18389.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26832.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23766.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20259.74},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23100.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8055.41,"10th_percentile":8055.41,"90th_percentile":8055.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders Without Cc/Mcc","code_information":[{"code":"370","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7650.63,"maximum":14416.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10930.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12643.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12102.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11423.04},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7650.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9171.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14416.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9581.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13980.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12383.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10556.15},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12036.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Cc","code_information":[{"code":"378","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10706.3,"maximum":20174.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15295.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17692.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16936.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15985.41},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10706.3},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12834.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20174.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13408.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19564.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17328.97},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14772.28},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16843.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6246.46,"10th_percentile":6246.46,"90th_percentile":6246.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6106.19,"10th_percentile":2221.78,"90th_percentile":11261.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7019.5,"10th_percentile":7019.5,"90th_percentile":7019.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Cc","code_information":[{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10658.27,"maximum":20084.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15227.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17613.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16860.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15913.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10658.27},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12776.84},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20084.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13348.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19477.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17251.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14706.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16768.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5125.72,"10th_percentile":5125.72,"90th_percentile":5125.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses With Cc","code_information":[{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10215.04,"maximum":19249.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14594.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16880.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16159.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15251.91},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10215.04},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12245.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19249.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12793.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18667.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16533.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14094.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16070.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures Without Cc/Mcc","code_information":[{"code":"407","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24231.37,"maximum":45661.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34619.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40043.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38332.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36179.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24231.37},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29047.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45661.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30347.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44281.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39220.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33433.83},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38122.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","code_information":[{"code":"415","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22562.16,"maximum":42515.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32234.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37285.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35691.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33687.21},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22562.16},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27046.9},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42515.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28257.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41230.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36518.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31130.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35496.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","code_information":[{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45338.3,"maximum":85434.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":64774.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74924.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71722.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67693.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45338.3},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54350.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":85434.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56782.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82852.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73383.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62556.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71329.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Mcc","code_information":[{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21486.84,"maximum":40489.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30698.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35508.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33990.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32081.66},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21486.84},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25757.83},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40489.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26910.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39265.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34778.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29647.0},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33804.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","code_information":[{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6783.82,"maximum":12783.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9691.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11210.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10731.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10128.82},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6783.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8132.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12783.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8496.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12396.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10980.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9360.15},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10672.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":19754.52,"10th_percentile":19754.52,"90th_percentile":19754.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9265.25,"10th_percentile":9265.25,"90th_percentile":9265.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46296.81,"maximum":87241.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66143.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76508.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73238.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69125.04},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46296.81},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55499.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":87241.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57982.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84603.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74934.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63879.17},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72837.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement Or Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With","code_information":[{"code":"463","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62221.44,"maximum":117249.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":88895.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102824.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98430.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92901.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62221.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74589.36},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":117249.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77927.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113705.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100710.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85851.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97890.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Mcc","code_information":[{"code":"471","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":52714.92,"maximum":99335.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":75313.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87114.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":83391.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78707.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52714.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63193.2},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":99335.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66020.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96332.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85323.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72734.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82934.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"479","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20293.61,"maximum":38241.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28993.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33536.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32103.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30300.07},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20293.61},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24327.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38241.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25416.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37085.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32846.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28000.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31927.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","code_information":[{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19311.08,"maximum":36389.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27589.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31912.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30548.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28833.07},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19311.08},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23149.59},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36389.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24185.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35289.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31256.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26644.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30381.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","code_information":[{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32934.41,"maximum":62061.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47053.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54426.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52100.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49173.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32934.41},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39480.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62061.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41247.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60185.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53306.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45442.06},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51814.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Thumb Or Joint Procedures","code_information":[{"code":"506","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14729.22,"maximum":27755.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21043.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24340.92},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23300.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21991.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14729.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17656.98},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27755.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18447.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26916.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23840.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20323.0},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23172.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","code_information":[{"code":"515","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34791.39,"maximum":65560.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49706.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57494.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55037.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51946.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34791.39},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41706.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65560.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43573.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63578.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56312.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48004.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54736.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur With Mcc","code_information":[{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17114.58,"maximum":32250.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24451.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28282.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27074.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25553.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17114.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20516.49},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32250.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21434.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31275.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27701.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23614.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26925.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis Without Cc/Mcc","code_information":[{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8596.05,"maximum":16198.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12281.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14205.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13598.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12834.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8596.05},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10304.7},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16198.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10765.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15708.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13913.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11860.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13523.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Cc","code_information":[{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13179.0,"maximum":24834.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18828.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21779.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20848.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19677.36},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13179.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15798.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24834.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16505.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24083.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21331.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18184.05},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20734.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5285.15,"10th_percentile":5285.15,"90th_percentile":5285.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tendonitis, Myositis And Bursitis With Mcc","code_information":[{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16232.49,"maximum":30588.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23191.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26825.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25678.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24236.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16232.49},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19459.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30588.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20329.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29663.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26273.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22397.17},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25538.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","code_information":[{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10637.52,"maximum":20045.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15197.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17579.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16827.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15882.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10637.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12751.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20045.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13322.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19439.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17217.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.39},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16735.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":5684.87,"10th_percentile":5684.87,"90th_percentile":5684.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13310.89,"10th_percentile":13310.89,"90th_percentile":13310.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":53506.4,"maximum":100826.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":76444.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88422.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84643.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79889.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53506.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64142.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":100826.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67012.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97778.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86604.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73826.78},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84179.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","code_information":[{"code":"584","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23370.02,"maximum":44038.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33388.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38620.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36969.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34893.41},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23370.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28015.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44038.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29268.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42706.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37826.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32245.36},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36767.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Cc","code_information":[{"code":"598","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12350.4,"maximum":23272.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17644.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20409.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19537.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18440.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12350.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14805.32},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23272.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15467.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22569.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19990.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17040.77},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19430.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Skin Disorders With Mcc","code_information":[{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16519.6,"maximum":31129.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23601.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27299.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26132.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24665.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16519.6},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19803.25},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31129.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20689.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30188.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26738.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22793.33},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25989.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity With Cc","code_information":[{"code":"620","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17470.48,"maximum":32921.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24959.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28871.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27637.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26084.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17470.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20943.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32921.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21880.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31925.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28277.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24105.32},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27485.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc Or Insertion Of Antibiotic-Eluti","code_information":[{"code":"628","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40685.48,"maximum":76667.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58126.9},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67235.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64361.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60746.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40685.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48772.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":76667.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50955.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74349.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65852.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56136.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64009.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inborn And Other Disorders Of Metabolism","code_information":[{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15525.07,"maximum":29255.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22180.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25656.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24559.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23180.23},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18611.02},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29255.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19443.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28370.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25128.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21421.09},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24425.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Cc","code_information":[{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30559.96,"maximum":57586.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43660.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50502.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48343.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45628.59},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30559.96},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36634.44},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":57586.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38273.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55846.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49463.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42165.86},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48078.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Mcc","code_information":[{"code":"662","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33422.4,"maximum":62980.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47750.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55232.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52872.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49902.45},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33422.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40065.85},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62980.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41858.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61076.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54096.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46115.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52582.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures Without Cc/Mcc","code_information":[{"code":"670","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10669.18,"maximum":20104.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15242.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17631.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16877.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15929.99},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10669.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12789.93},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20104.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13362.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19497.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17268.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14721.07},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16785.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure Without Cc/Mcc","code_information":[{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6553.48,"maximum":12349.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9362.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10830.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10367.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9784.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6553.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7856.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12349.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8207.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11975.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10607.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9042.32},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10310.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"1 through 10","median_amount":11214.36,"10th_percentile":11214.36,"90th_percentile":11214.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Signs And Symptoms With Mcc","code_information":[{"code":"695","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12486.86,"maximum":23530.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17839.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20635.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19753.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18643.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12486.86},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14968.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23530.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15638.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22818.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20210.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17229.06},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19645.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":17590.3,"10th_percentile":17590.3,"90th_percentile":17590.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures With Cc/Mcc","code_information":[{"code":"709","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25404.95,"maximum":47872.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36295.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41983.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40189.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37931.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25404.95},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30454.76},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":47872.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31817.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46425.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41119.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35053.11},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39968.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures With Cc/Mcc","code_information":[{"code":"717","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20638.59,"maximum":38891.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29486.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34106.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32648.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30815.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20638.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24740.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38891.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37715.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33405.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28476.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32470.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammation Of The Male Reproductive System Without Mcc","code_information":[{"code":"728","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8855.87,"maximum":16687.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12652.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14634.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14009.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13222.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8855.87},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10616.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16687.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11091.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16183.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14333.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12219.11},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13932.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","code_information":[{"code":"739","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39113.43,"maximum":73704.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55880.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64637.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61874.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58399.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39113.43},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46888.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73704.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48986.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71476.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63308.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53967.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61535.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","code_information":[{"code":"747","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9385.34,"maximum":17685.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13408.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15509.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14847.02},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14013.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9385.34},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11250.89},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17685.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11754.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17151.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15190.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12949.66},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14765.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System With Cc","code_information":[{"code":"758","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10687.74,"maximum":20139.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15269.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17662.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16907.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15957.7},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10687.74},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12812.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20139.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13385.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19531.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17298.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14746.68},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16814.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7953.42,"10th_percentile":7953.42,"90th_percentile":7953.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion Without D&C","code_information":[{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9184.47,"maximum":17307.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13121.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15177.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14529.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13713.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9184.47},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11010.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17307.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11502.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16783.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14865.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12672.5},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14449.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":7132.64,"10th_percentile":7132.64,"90th_percentile":7132.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","code_information":[{"code":"790","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":64885.19,"maximum":122268.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":92700.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107226.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102644.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96879.05},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64885.19},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77782.58},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":122268.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81263.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118572.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105021.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89526.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102081.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","code_information":[{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10448.66,"maximum":19689.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14927.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17267.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16529.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15600.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10448.66},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12525.57},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19689.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13086.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19094.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16911.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14416.8},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16438.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Cc","code_information":[{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8231.42,"maximum":15511.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11760.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13602.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13021.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12290.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8231.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9867.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15511.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10309.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15042.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13323.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11357.5},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12950.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4509.51,"10th_percentile":4509.51,"90th_percentile":4509.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":13620.29,"10th_percentile":13620.29,"90th_percentile":13620.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7561.0,"10th_percentile":7561.0,"90th_percentile":7561.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4734.99,"10th_percentile":4734.99,"90th_percentile":4734.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4593.01,"10th_percentile":4593.01,"90th_percentile":5041.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6266.45,"10th_percentile":6266.45,"90th_percentile":6266.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9451.27,"10th_percentile":9451.27,"90th_percentile":9451.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":7714.15,"10th_percentile":7714.15,"90th_percentile":7714.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9893.5,"10th_percentile":9893.5,"90th_percentile":9893.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":7130.0,"10th_percentile":5760.8,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3832.24,"10th_percentile":3832.24,"90th_percentile":3832.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders With Mcc","code_information":[{"code":"814","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23217.18,"maximum":43750.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33170.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38367.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36728.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34665.21},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23217.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27832.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43750.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29077.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42427.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37578.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32034.48},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36526.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","code_information":[{"code":"822","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13144.07,"maximum":24768.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18778.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21721.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20793.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13144.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.75},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24768.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16461.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24019.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21274.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18135.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20679.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","code_information":[{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16430.09,"maximum":30960.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23473.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27151.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25991.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24531.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16430.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19695.94},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30960.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20577.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30024.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26593.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22669.82},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25848.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis With Cc Or High Dose Chemotherapy Agent","code_information":[{"code":"838","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22788.15,"maximum":42941.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32557.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37658.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36049.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34024.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22788.15},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27317.8},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42941.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28540.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41643.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36884.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31442.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35851.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","code_information":[{"code":"846","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28302.32,"maximum":53332.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40435.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46771.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44772.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42257.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28302.32},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33928.05},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53332.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35446.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51720.38},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45809.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39050.83},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44527.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","code_information":[{"code":"856","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49658.16,"maximum":93575.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70946.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82063.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78556.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74143.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49658.16},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59528.84},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":93575.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62192.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90746.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80375.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68517.07},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78125.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Mcc","code_information":[{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22851.46,"maximum":43061.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32647.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37763.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36149.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34119.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22851.46},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27393.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43061.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28619.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41759.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36986.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31529.87},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35951.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Depressive Neuroses","code_information":[{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10271.81,"maximum":19356.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14675.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16974.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16249.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15336.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10271.81},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12313.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19356.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12864.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18770.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16625.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14172.78},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16160.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","code_information":[{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15454.11,"maximum":29121.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22079.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25538.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24447.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23074.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15454.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18525.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29121.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19354.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28241.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25013.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21323.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24313.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Procedures For Injuries","code_information":[{"code":"906","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21444.26,"maximum":40409.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30637.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35437.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33923.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32018.09},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21444.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25706.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40409.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26857.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39187.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34709.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29588.25},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33737.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs With Mcc","code_information":[{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17122.22,"maximum":32264.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24462.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28295.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27086.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25564.92},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17122.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20525.65},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32264.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21444.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31289.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27713.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23624.81},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26937.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","code_information":[{"code":"928","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":78304.37,"maximum":147555.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111872.6},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":129402.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123872.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116915.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78304.37},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93869.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":147555.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98069.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143095.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126741.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108042.38},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123193.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation With Cc/Mcc","code_information":[{"code":"945","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16906.07,"maximum":31857.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24153.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27938.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26744.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25242.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16906.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20266.53},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31857.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21173.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30894.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27363.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23326.56},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26597.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","code_information":[{"code":"956","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41080.67,"maximum":77411.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58691.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67888.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64987.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61336.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41080.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49246.38},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":77411.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51450.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75071.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66492.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56682.07},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64630.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures Without Mcc","code_information":[{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28792.5,"maximum":54256.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41135.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47581.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45547.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42989.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28792.5},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34515.65},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":54256.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36060.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52616.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46602.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39727.16},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45298.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"987","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37427.84,"maximum":70528.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53472.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61851.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59208.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55882.92},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37427.84},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44867.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":70528.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46875.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68396.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60579.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51641.99},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58883.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Transplant Or Implant Of Heart Assist System With Mcc","code_information":[{"code":"001","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":305936.92,"maximum":576503.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":437088.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":505579.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":483972.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":456789.57},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":305936.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366748.78},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":576503.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":383159.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":559076.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":495182.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":422124.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":481320.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas Or Islet Cell Transplant","code_information":[{"code":"010","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":78337.12,"maximum":147617.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111919.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":129456.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123924.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116963.91},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78337.12},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93908.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":147617.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98110.55},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":143155.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126794.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108087.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123245.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas, Islet Cell And Kidney Transplant With Hemodialysis","code_information":[{"code":"019","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":77888.43,"maximum":146771.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":111278.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":128715.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":123214.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116293.98},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77888.43},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93370.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":146771.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97548.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142335.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126068.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107468.48},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122539.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","code_information":[{"code":"027","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27542.5,"maximum":51900.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39349.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45515.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43570.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41123.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27542.5},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33017.19},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51900.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34494.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50331.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44579.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38002.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43331.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Cc","code_information":[{"code":"035","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26097.09,"maximum":49177.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37284.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43127.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41283.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38965.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26097.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31284.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49177.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32684.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47690.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42240.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36008.1},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41057.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries With Cc/Mcc","code_information":[{"code":"052","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19773.96,"maximum":37261.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28250.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32677.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31281.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29524.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19773.96},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23704.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37261.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24765.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36135.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32005.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27283.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31109.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","code_information":[{"code":"060","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10041.46,"maximum":18922.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14346.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16594.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15884.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14992.74},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10041.46},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12037.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18922.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12576.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18350.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16252.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13854.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15797.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Precerebral Occlusion Without Infarction Without Mcc","code_information":[{"code":"068","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9436.65,"maximum":17782.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13482.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15594.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14928.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14089.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9436.65},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11312.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17782.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11818.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17244.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15273.95},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13020.46},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14846.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Meningitis Without Cc/Mcc","code_information":[{"code":"076","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9008.71,"maximum":16975.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12870.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14887.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14251.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13450.76},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9008.71},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10799.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16975.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11282.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16462.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14581.28},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12429.99},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14173.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","code_information":[{"code":"087","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9985.78,"maximum":18817.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14266.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16502.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15796.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14909.61},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9985.78},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11970.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18817.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12506.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18248.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16162.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13778.13},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15710.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Cc","code_information":[{"code":"095","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28157.13,"maximum":53058.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":40227.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46531.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44542.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42040.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28157.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33753.99},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":53058.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35264.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51455.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45574.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38850.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44298.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches Without Mcc","code_information":[{"code":"103","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9129.89,"maximum":17204.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13043.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15087.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14442.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13631.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9129.89},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10944.66},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17204.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11434.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16684.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14777.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12597.19},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14363.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neurological Eye Disorders","code_information":[{"code":"123","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8718.32,"maximum":16428.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12455.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14407.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13791.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13017.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8718.32},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10451.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16428.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10918.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15932.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14111.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12029.31},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13716.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Mcc","code_information":[{"code":"140","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46564.28,"maximum":87745.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66525.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76950.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73661.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69524.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46564.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55819.98},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":87745.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58317.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85092.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75367.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64248.21},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73258.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","code_information":[{"code":"148","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8701.94,"maximum":16397.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12432.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14380.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13765.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12992.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8701.94},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10431.65},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16397.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10898.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15902.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14084.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12006.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13690.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","code_information":[{"code":"156","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7544.74,"maximum":14217.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10779.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12468.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11935.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11264.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7544.74},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9044.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14217.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9449.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13787.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12211.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10410.04},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11869.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Cc","code_information":[{"code":"167","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19687.72,"maximum":37099.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28127.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32535.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31144.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29395.42},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19687.72},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23601.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37099.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24657.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35977.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31866.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27164.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30974.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Mcc","code_information":[{"code":"180","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19279.42,"maximum":36329.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27544.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31860.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30498.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28785.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19279.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23111.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36329.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24145.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35231.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31205.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26601.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30331.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion Without Cc/Mcc","code_information":[{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7829.67,"maximum":14754.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11186.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12939.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12386.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11690.36},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7829.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9386.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14754.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9806.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14308.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12672.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10803.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12318.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease With Mcc","code_information":[{"code":"196","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20602.56,"maximum":38823.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29434.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34046.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32591.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30761.36},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20602.56},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24697.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38823.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25802.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37649.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33346.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28426.89},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32413.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":11859.88,"10th_percentile":11859.88,"90th_percentile":11859.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Signs And Symptoms","code_information":[{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8814.39,"maximum":16609.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12593.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14566.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13943.8},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13160.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8814.39},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10566.44},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16609.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11039.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16107.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14266.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12161.87},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13867.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Heart Assist System Implant","code_information":[{"code":"215","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":108700.57,"maximum":204834.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":155299.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179634.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":171957.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162299.1},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108700.57},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130307.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":204834.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":136138.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198642.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":175940.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":149982.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":171014.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures Without Mcc","code_information":[{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34383.09,"maximum":64791.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49122.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56820.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54391.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51336.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34383.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41217.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64791.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43061.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62832.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55651.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47440.92},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54093.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","code_information":[{"code":"240","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31118.91,"maximum":58640.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44459.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51425.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49228.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46463.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31118.91},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37304.49},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":58640.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38973.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56867.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50368.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42937.08},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48958.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures With Mcc","code_information":[{"code":"252","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38081.77,"maximum":71760.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54407.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62932.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60242.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56859.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38081.77},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45651.38},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":71760.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47694.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69591.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61638.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52544.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59912.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement With Mcc","code_information":[{"code":"260","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35510.82,"maximum":66916.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50733.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58683.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56175.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53020.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35510.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42569.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66916.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44474.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64893.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57476.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48996.93},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55867.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","code_information":[{"code":"268","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":75086.03,"maximum":141491.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":107274.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124084.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":118781.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":112109.77},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75086.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90011.08},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":141491.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94038.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137214.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":121532.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103601.81},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118130.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","code_information":[{"code":"276","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":65574.05,"maximum":123566.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93684.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108365.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":103733.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97907.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65574.05},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78608.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":123566.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82125.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":119831.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106136.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90477.42},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103165.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Cc","code_information":[{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7556.75,"maximum":14239.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10796.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12487.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11954.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11282.86},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7556.75},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9058.82},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14239.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9464.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13809.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12231.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10426.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11888.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock With Cc","code_information":[{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9268.53,"maximum":17465.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13241.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15316.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14662.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13838.7},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9268.53},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11110.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17465.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11608.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16937.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15001.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12788.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14581.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis With Mcc","code_information":[{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13063.28,"maximum":24616.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18663.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21587.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20665.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19504.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13063.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15659.9},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24616.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16360.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23872.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21143.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18024.39},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20552.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","code_information":[{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6180.11,"maximum":11645.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8829.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10213.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9776.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9227.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6180.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7408.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11645.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7740.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11293.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10002.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8527.16},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9722.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy Without Intraluminal Device","code_information":[{"code":"318","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26443.16,"maximum":49829.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37779.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43698.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41831.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39481.86},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26443.16},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31699.33},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49829.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33117.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48322.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42800.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36485.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41602.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Mcc","code_information":[{"code":"326","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":54447.45,"maximum":102600.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":77788.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89977.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86132.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81294.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54447.45},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65270.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":102600.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68190.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99498.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88127.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75125.21},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85660.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":43273.6,"10th_percentile":43273.6,"90th_percentile":43273.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection Without Cc/Mcc","code_information":[{"code":"334","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17880.95,"maximum":33694.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25546.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29549.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28286.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26697.77},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17880.95},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21435.2},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33694.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22394.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32676.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28941.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24671.69},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28131.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Cc","code_information":[{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14288.17,"maximum":26924.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20413.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23612.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22602.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21333.44},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14288.17},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17128.27},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26924.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17894.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26110.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23126.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19714.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22479.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures With Mcc","code_information":[{"code":"356","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47956.2,"maximum":90368.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":68514.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79250.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75863.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71602.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47956.2},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57488.57},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":90368.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60061.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87636.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77620.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66168.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75447.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","code_information":[{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19356.93,"maximum":36475.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27655.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31988.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30621.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28901.53},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19356.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23204.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36475.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24242.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35373.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31330.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26708.21},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30453.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12683.58,"10th_percentile":12683.58,"90th_percentile":12683.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":3244.62,"10th_percentile":3244.62,"90th_percentile":3244.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage Without Cc/Mcc","code_information":[{"code":"379","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6882.08,"maximum":12968.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9832.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11373.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10887.01},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10275.52},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6882.08},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8250.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12968.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8619.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12576.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11139.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9495.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10827.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":3065.25,"10th_percentile":3065.25,"90th_percentile":3065.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease Without Cc/Mcc","code_information":[{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7437.75,"maximum":14015.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10626.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12291.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11766.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11105.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7437.75},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8916.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14015.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9315.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13591.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12038.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10262.42},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11701.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses Without Cc/Mcc","code_information":[{"code":"395","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7085.13,"maximum":13351.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10122.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11708.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11208.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10578.7},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7085.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8493.46},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13351.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8873.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12947.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11467.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9775.89},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11146.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6379.51,"10th_percentile":6379.51,"90th_percentile":6379.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. With Mcc","code_information":[{"code":"408","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38925.66,"maximum":73351.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55612.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64326.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61577.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58119.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38925.66},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46663.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73351.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48751.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71133.72},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63004.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53708.63},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61240.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","code_information":[{"code":"416","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14883.15,"maximum":28045.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21263.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24595.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23544.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22221.79},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14883.15},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17841.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28045.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18639.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27197.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24089.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20535.39},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23415.15}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","code_information":[{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23885.3,"maximum":45009.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34124.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39471.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37785.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35662.77},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23885.3},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28633.05},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45009.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29914.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43648.61},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38660.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32956.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37577.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Cc","code_information":[{"code":"433","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11530.54,"maximum":21728.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16473.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19054.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18240.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17216.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11530.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13822.49},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21728.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14441.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21071.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18663.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15909.54},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18140.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","code_information":[{"code":"441","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19592.74,"maximum":36920.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27991.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32378.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30994.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29253.61},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19592.74},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23487.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36920.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24538.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35804.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31712.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27033.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30824.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":58183.24,"maximum":109639.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":83125.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":96151.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":92042.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86872.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58183.24},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69748.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":109639.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72869.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":106325.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94174.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80279.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91537.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement Or Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders With","code_information":[{"code":"464","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34003.18,"maximum":64075.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48579.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56192.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53790.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50769.61},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34003.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40762.08},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64075.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42586.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62138.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55036.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46916.73},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53496.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Cc","code_information":[{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32162.57,"maximum":60606.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45950.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53150.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50879.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48021.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32162.57},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38555.61},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":60606.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40280.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58774.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52057.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44377.1},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50600.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Mcc Or Insertion Of Antibiotic-Eluting Bone Void Fi","code_information":[{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31793.58,"maximum":59911.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45423.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52540.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50295.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47470.49},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31793.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38113.27},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59911.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39818.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58100.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51460.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43867.97},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50019.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":35164.55,"10th_percentile":35164.55,"90th_percentile":35164.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"489","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12192.11,"maximum":22974.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17418.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20148.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19287.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18203.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12192.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14615.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22974.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15269.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22280.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19733.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16822.36},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19181.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4114.47,"10th_percentile":4114.47,"90th_percentile":4114.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","code_information":[{"code":"499","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21995.57,"maximum":41448.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31424.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36349.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34795.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32841.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21995.57},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26367.69},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41448.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27547.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40195.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35601.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30348.93},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34604.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","code_information":[{"code":"507","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19720.47,"maximum":37161.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28174.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32589.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31196.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29444.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19720.47},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23640.36},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37161.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24698.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36037.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31919.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27209.8},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31025.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","code_information":[{"code":"516","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22686.62,"maximum":42750.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32412.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37491.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35888.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33873.03},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22686.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27196.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42750.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28413.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41458.1},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36720.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31302.42},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35692.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur Without Mcc","code_information":[{"code":"534","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8800.19,"maximum":16582.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12572.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14542.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13921.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13139.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8800.19},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10549.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16582.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11021.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16081.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14243.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12142.28},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13845.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","code_information":[{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19284.88,"maximum":36340.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27552.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31869.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30507.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28793.95},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19284.88},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23118.19},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36340.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24152.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35241.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31214.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26608.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30340.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":11113.67,"10th_percentile":11113.67,"90th_percentile":11113.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":13728.34,"10th_percentile":13728.34,"90th_percentile":13728.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis Without Cc/Mcc","code_information":[{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9542.55,"maximum":17981.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13633.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15769.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15095.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14247.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9542.55},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11439.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17981.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11951.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17438.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15445.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13166.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15012.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tendonitis, Myositis And Bursitis Without Mcc","code_information":[{"code":"558","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9751.06,"maximum":18374.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13931.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16114.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15425.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14559.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9751.06},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11689.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18374.79},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12212.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17819.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15782.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13454.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15341.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":10745.14,"10th_percentile":10745.14,"90th_percentile":10745.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","code_information":[{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8180.11,"maximum":15414.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11686.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13518.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12940.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12213.59},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8180.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9806.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15414.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10244.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14948.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13240.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11286.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12869.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"577","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28937.69,"maximum":54529.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41342.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47821.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45777.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43206.41},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28937.69},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34689.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":54529.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36241.99},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52881.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46837.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39927.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45526.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","code_information":[{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21059.98,"maximum":39685.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30088.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34802.89},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33315.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31444.33},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21059.98},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25246.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39685.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26375.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38485.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34087.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29058.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33132.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders Without Cc/Mcc","code_information":[{"code":"599","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8399.54,"maximum":15827.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12000.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13880.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13287.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12541.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8399.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10069.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15827.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10519.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15349.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13595.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11589.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13214.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Skin Disorders Without Mcc","code_information":[{"code":"607","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9895.17,"maximum":18646.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14137.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16352.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15653.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14774.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9895.17},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11862.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18646.33},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12392.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18082.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16016.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13653.1},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15567.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity Without Cc/Mcc","code_information":[{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16467.2,"maximum":31030.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23526.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27213.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26050.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24586.92},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16467.2},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19740.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31030.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20623.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30092.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26653.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22721.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25907.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","code_information":[{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23785.96,"maximum":44821.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33982.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39307.73},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37627.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35514.44},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23785.96},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28513.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44821.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29789.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43467.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38499.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32819.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37421.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Mcc","code_information":[{"code":"643","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17970.47,"maximum":33863.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25674.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29697.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28428.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26831.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17970.47},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21542.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33863.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22506.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32839.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29086.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24795.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28272.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":5702.48,"10th_percentile":5702.48,"90th_percentile":5702.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures Without Cc/Mcc","code_information":[{"code":"655","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23106.92,"maximum":43542.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33012.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38185.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36553.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34500.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23106.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27699.94},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43542.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28939.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42226.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37400.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31882.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36353.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Cc","code_information":[{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16596.02,"maximum":31273.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23710.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27425.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26253.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24779.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16596.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19894.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31273.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20785.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30327.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26861.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22898.77},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26109.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures With Cc/Mcc","code_information":[{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19596.02,"maximum":36926.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27996.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32383.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30999.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29258.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19596.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23491.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36926.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24542.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35810.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31717.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27038.09},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30829.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms With Mcc","code_information":[{"code":"686","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19690.99,"maximum":37105.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28132.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32540.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31149.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29400.31},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19690.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23605.02},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37105.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24661.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35983.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31871.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27169.13},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30979.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Signs And Symptoms Without Mcc","code_information":[{"code":"696","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7521.81,"maximum":14174.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10746.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12430.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11899.03},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11230.7},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7521.81},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9016.94},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14174.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9420.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13745.55},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12174.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10378.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11833.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures Without Cc/Mcc","code_information":[{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15296.9,"maximum":28825.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21854.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25279.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24198.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22839.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15296.9},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18337.5},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28825.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19158.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27953.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24759.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21106.28},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24066.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"718","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14662.62,"maximum":27630.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20948.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24230.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23195.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21892.53},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14662.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17577.15},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27630.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18363.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26794.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23732.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20231.12},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23068.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses With Cc/Mcc","code_information":[{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11557.83,"maximum":21779.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16512.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19100.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18283.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17256.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11557.83},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13855.21},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21779.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14475.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21121.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18707.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15947.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18183.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","code_information":[{"code":"740","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19755.4,"maximum":37226.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28224.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32646.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31251.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29496.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19755.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23682.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37226.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24741.96},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36101.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31975.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27258.0},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31080.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Female Reproductive System Reconstructive Procedures","code_information":[{"code":"748","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15145.15,"maximum":28539.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21637.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25028.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23958.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22612.99},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15145.15},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18155.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28539.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18968.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27676.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24513.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20896.9},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23827.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"759","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7244.52,"maximum":13651.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10350.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11972.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11460.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10816.68},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7244.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8684.53},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13651.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9073.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13238.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11725.81},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9995.81},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11397.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Mcc","code_information":[{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26802.33,"maximum":50505.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38292.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44292.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42399.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40018.13},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26802.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32129.89},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50505.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33567.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48979.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43381.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36981.17},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42167.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prematurity With Major Problems","code_information":[{"code":"791","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":44312.1,"maximum":83501.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":63308.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73228.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70098.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66161.7},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44312.1},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53120.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":83501.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55497.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80977.05},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71722.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61140.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69714.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6165.31,"10th_percentile":6165.31,"90th_percentile":6165.31},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Mcc","code_information":[{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49442.0,"maximum":93167.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70637.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81705.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78214.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":73821.07},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49442.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59269.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":93167.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61921.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90351.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80025.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68218.82},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77785.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","code_information":[{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7360.24,"maximum":13869.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10515.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12163.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11643.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10989.46},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7360.24},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8823.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13869.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9218.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13450.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11913.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10155.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11579.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5582.71,"10th_percentile":4921.58,"90th_percentile":5976.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":11004.44,"10th_percentile":6362.3,"90th_percentile":15142.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":7502.55,"10th_percentile":4379.44,"90th_percentile":8021.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5651.89,"10th_percentile":5651.89,"90th_percentile":5651.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":10976.5,"10th_percentile":10976.5,"90th_percentile":10976.5},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":13325.38,"10th_percentile":13325.38,"90th_percentile":13325.38},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7216.21,"10th_percentile":7216.21,"90th_percentile":7216.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"1 through 10","median_amount":7698.65,"10th_percentile":7438.4,"90th_percentile":7714.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8713.55,"10th_percentile":7669.8,"90th_percentile":8713.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"22","median_amount":7130.0,"10th_percentile":5715.66,"90th_percentile":7201.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5177.53,"10th_percentile":5091.21,"90th_percentile":5477.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Reticuloendothelial And Immunity Disorders With Cc","code_information":[{"code":"815","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11069.84,"maximum":20859.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15815.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18293.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17511.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16528.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11069.84},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13270.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20859.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13864.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20229.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17917.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15273.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17415.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","code_information":[{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50052.26,"maximum":94317.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71509.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82714.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79179.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74732.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50052.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60001.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":94317.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62686.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91466.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81013.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69060.84},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78745.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","code_information":[{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13127.69,"maximum":24737.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18755.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21694.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20767.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19600.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13127.69},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15737.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24737.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16441.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23989.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21248.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18113.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20653.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"839","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15763.06,"maximum":29703.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22520.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26049.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24936.15},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23535.57},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15763.06},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18896.32},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29703.71},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19741.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28805.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25513.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21749.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24799.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","code_information":[{"code":"847","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14281.62,"maximum":26912.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20404.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23601.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22592.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21323.66},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14281.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17120.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26912.11},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17886.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26098.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23115.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19705.42},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22468.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","code_information":[{"code":"857","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23378.76,"maximum":44054.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33400.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38634.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36983.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34906.45},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23378.76},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28025.81},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44054.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29279.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42722.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37840.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32257.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36781.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":22712.36,"10th_percentile":22712.36,"90th_percentile":22712.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Cc","code_information":[{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11256.52,"maximum":21211.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16082.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18602.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17807.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16806.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11256.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13494.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21211.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14097.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20570.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18219.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15531.46},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17709.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neuroses Except Depressive","code_information":[{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11722.67,"maximum":22090.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16748.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19372.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18544.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17502.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11722.67},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14052.82},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22090.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14681.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21422.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18974.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16174.65},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18442.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","code_information":[{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19051.26,"maximum":35899.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27218.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31483.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30137.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28445.13},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19051.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22838.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35899.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23860.07},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34814.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30835.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26286.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29972.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":55801.26,"10th_percentile":55801.26,"90th_percentile":55801.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11802.73,"10th_percentile":11802.73,"90th_percentile":11802.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":18670.76,"10th_percentile":18670.76,"90th_percentile":18670.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4774.24,"10th_percentile":4774.24,"90th_percentile":4774.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries With Mcc","code_information":[{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41913.64,"maximum":78981.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":59881.56},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69264.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66304.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62580.59},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41913.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50244.92},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":78981.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52493.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76594.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67840.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57831.38},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65941.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs Without Mcc","code_information":[{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9356.96,"maximum":17632.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13368.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15462.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14802.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13970.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9356.96},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11216.87},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17632.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11718.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17099.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15144.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12910.5},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14720.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":1393.56,"10th_percentile":1393.56,"90th_percentile":1393.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6081.14,"10th_percentile":6081.14,"90th_percentile":6081.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","code_information":[{"code":"929","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35161.47,"maximum":66257.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50234.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58106.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55623.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52499.04},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35161.47},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42150.61},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66257.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44036.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64254.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56911.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48514.91},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55318.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation Without Cc/Mcc","code_information":[{"code":"946","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12519.62,"maximum":23591.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17886.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20689.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19805.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18692.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12519.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15008.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23591.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15679.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22878.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20263.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17274.25},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19696.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma With Mcc","code_information":[{"code":"957","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":83186.45,"maximum":156755.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":118847.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":137470.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":131595.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124204.37},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83186.45},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99721.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":156755.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104183.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":152017.01},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134643.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114778.55},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130874.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Mcc","code_information":[{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31506.46,"maximum":59370.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45012.94},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52066.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49841.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47041.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31506.46},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37769.08},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59370.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39459.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57575.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50995.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43471.82},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49568.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"988","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17943.18,"maximum":33811.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25635.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29652.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28384.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26790.68},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17943.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21509.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33811.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22472.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32789.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29042.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24757.55},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28229.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":15302.17,"10th_percentile":15302.17,"90th_percentile":15302.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":25848.11,"10th_percentile":25848.11,"90th_percentile":25848.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Syncope And Collapse","code_information":[{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9515.26,"maximum":17930.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13594.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15724.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15052.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14207.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9515.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11406.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17930.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11917.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17388.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15401.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13128.91},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14970.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6110.03,"10th_percentile":6110.03,"90th_percentile":6110.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12826.3,"10th_percentile":12826.3,"90th_percentile":12826.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6042.26,"10th_percentile":6042.26,"90th_percentile":6042.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":2570.51,"10th_percentile":2570.51,"90th_percentile":2570.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endovascular Cardiac Valve Procedures Without Mcc","code_information":[{"code":"320","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26258.66,"maximum":49481.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":37515.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43394.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41539.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39206.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26258.66},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31478.16},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":49481.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32886.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47985.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42501.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36231.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41311.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","code_information":[{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17492.31,"maximum":32962.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24991.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28907.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27671.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26117.49},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17492.31},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20969.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32962.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21907.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31965.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28312.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24135.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27520.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Cc","code_information":[{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23020.68,"maximum":43379.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32889.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38043.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36417.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34371.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23020.68},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27596.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43379.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28831.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42068.57},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37260.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31763.35},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36217.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7922.66,"10th_percentile":7922.66,"90th_percentile":7922.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":15952.41,"10th_percentile":15952.41,"90th_percentile":15952.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Mcc","code_information":[{"code":"350","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27204.07,"maximum":51263.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38866.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44956.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43035.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40617.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27204.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32611.5},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51263.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34070.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49713.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44031.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37535.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42799.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"358","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15260.87,"maximum":28757.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21803.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25219.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24141.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22785.77},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15260.87},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18294.32},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28757.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19112.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27888.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24700.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21056.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24009.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6636.16,"10th_percentile":6636.16,"90th_percentile":6636.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","code_information":[{"code":"373","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7941.03,"maximum":14963.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11345.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13123.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12562.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11856.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7941.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9519.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14963.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9945.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14511.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12853.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10956.83},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12493.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9587.06,"10th_percentile":9587.06,"90th_percentile":9587.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Cc","code_information":[{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11828.57,"maximum":22289.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16899.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19547.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18712.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17661.05},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11828.57},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14179.76},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22289.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14814.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21615.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19145.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16320.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18609.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction With Cc","code_information":[{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8622.25,"maximum":16247.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12318.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14248.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13639.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12873.74},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8622.25},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10336.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16247.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10798.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13955.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11896.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13565.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":2977.3,"10th_percentile":2977.3,"90th_percentile":2977.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Cc","code_information":[{"code":"398","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16523.97,"maximum":31137.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23607.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27306.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26139.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24671.68},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16523.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19808.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31137.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20694.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30196.32},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26745.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22799.36},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25996.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","code_information":[{"code":"410","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17332.92,"maximum":32661.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24763.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28643.7},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27419.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25879.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17332.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20778.23},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32661.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21708.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31674.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28054.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23915.53},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27269.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","code_information":[{"code":"418","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18467.2,"maximum":34799.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26383.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30518.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29213.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27573.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18467.2},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22137.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34799.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23128.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33747.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29890.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25480.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29053.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":11445.43,"10th_percentile":11445.43,"90th_percentile":11445.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":16335.82,"10th_percentile":16335.82,"90th_percentile":16335.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"426","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":120318.44,"maximum":226726.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":171897.66},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":198833.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":190336.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":179645.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120318.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144234.44},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":226726.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":150688.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":219872.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":194744.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":166012.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":189292.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","code_information":[{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20051.25,"maximum":37784.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28647.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33135.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31719.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29938.21},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20051.25},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24036.89},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37784.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25112.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36642.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32454.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27666.21},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31545.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7638.62,"maximum":14394.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10913.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12623.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12083.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11405.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7638.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9156.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14394.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9566.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13959.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12363.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10539.58},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12017.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Or Infection With Mcc","code_information":[{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":91739.92,"maximum":172873.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":131067.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":151605.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":145126.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":136975.42},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91739.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109975.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":172873.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114896.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":167647.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148488.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126580.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144331.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Mcc","code_information":[{"code":"466","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":56827.35,"maximum":107084.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81188.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93910.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89897.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84848.02},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56827.35},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68123.07},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":107084.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71171.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103847.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91979.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78408.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89404.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc Or Insertion Of Antib","code_information":[{"code":"474","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46865.59,"maximum":88312.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":66956.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":77448.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74138.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69974.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46865.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56181.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":88312.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58695.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85643.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75855.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64663.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73732.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","code_information":[{"code":"482","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17805.63,"maximum":33552.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25438.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29424.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28167.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26585.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17805.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21344.9},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33552.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22300.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32538.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28819.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24567.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28013.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","code_information":[{"code":"493","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27686.6,"maximum":52172.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":39555.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45753.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43798.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41338.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27686.6},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33189.94},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":52172.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34675.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50595.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44812.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38201.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43558.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures With Cc","code_information":[{"code":"501","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19084.01,"maximum":35961.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27265.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31537.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30189.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28494.03},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19084.01},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22877.38},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35961.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23901.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34874.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30888.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26331.63},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30024.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","code_information":[{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32974.8,"maximum":62137.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47110.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54492.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52164.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49234.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32974.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39529.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62137.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41298.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60258.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53372.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45497.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51878.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","code_information":[{"code":"518","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40800.1,"maximum":76883.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":58290.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67424.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64543.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60917.99},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40800.1},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48910.05},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":76883.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51098.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74559.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66038.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56294.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64189.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Hip And Pelvis Without Mcc","code_information":[{"code":"536","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8816.57,"maximum":16613.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12596.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14569.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13947.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13163.88},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8816.57},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10569.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16613.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11042.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16111.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14270.29},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12164.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13870.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":11922.84,"10th_percentile":4326.23,"90th_percentile":16254.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6543.6,"10th_percentile":6543.6,"90th_percentile":7891.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","code_information":[{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8237.97,"maximum":15523.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11769.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13613.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13031.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12299.98},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8237.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9875.45},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15523.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10317.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15054.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13333.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11366.54},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12960.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8666.8,"10th_percentile":8666.8,"90th_percentile":8666.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems Without Mcc","code_information":[{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10494.51,"maximum":19775.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14993.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17342.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16601.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15669.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10494.51},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12580.53},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19775.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13143.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19177.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16986.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14480.06},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16510.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":2148.57,"10th_percentile":2148.57,"90th_percentile":2148.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":2996.52,"10th_percentile":2996.52,"90th_percentile":2996.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":12301.71,"10th_percentile":12301.71,"90th_percentile":12301.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6404.84,"10th_percentile":6404.84,"90th_percentile":6404.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12293.63,"maximum":23165.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17563.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20315.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19447.75},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18355.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12293.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14737.27},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23165.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15396.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22465.7},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19898.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16962.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19341.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5938.98,"10th_percentile":5938.98,"90th_percentile":5938.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Cc","code_information":[{"code":"571","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18444.27,"maximum":34756.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26351.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30480.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29177.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27538.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18444.27},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22110.49},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34756.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23099.87},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33705.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29853.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25448.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29017.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":22697.92,"10th_percentile":22697.92,"90th_percentile":22697.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","code_information":[{"code":"579","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35354.7,"maximum":66621.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50510.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58425.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55928.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52787.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35354.7},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42382.25},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66621.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44278.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64608.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57224.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48781.53},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55622.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers With Cc","code_information":[{"code":"593","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12950.84,"maximum":24404.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18502.72},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21402.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20487.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19336.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12950.84},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24404.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16219.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23666.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20961.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17869.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20375.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":10586.96,"10th_percentile":10586.96,"90th_percentile":10586.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Malignant Breast Disorders Without Cc/Mcc","code_information":[{"code":"601","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6604.79,"maximum":12445.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9436.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10914.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10448.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9861.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6604.79},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7917.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12445.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8271.93},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12069.75},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10690.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9113.12},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10391.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chest Pain","code_information":[{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7860.24,"maximum":14811.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11229.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12989.52},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12434.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11736.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7860.24},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9422.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14811.74},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9844.28},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14364.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12722.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10845.36},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12366.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":3216.84,"10th_percentile":3216.84,"90th_percentile":3216.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","code_information":[{"code":"321","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29702.97,"maximum":55971.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42436.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49085.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46988.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44349.04},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29702.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35607.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":55971.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37200.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54279.96},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48076.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40983.41},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46730.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures With Mcc","code_information":[{"code":"329","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50179.99,"maximum":94558.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":71691.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82925.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":79381.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74922.95},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50179.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60154.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":94558.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62846.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91700.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81220.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69237.08},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78946.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":50901.25,"10th_percentile":50901.25,"90th_percentile":50901.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":31012.93,"10th_percentile":31012.93,"90th_percentile":31012.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6621.68,"10th_percentile":6621.68,"90th_percentile":6621.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis Without Cc/Mcc","code_information":[{"code":"337","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16757.6,"maximum":31577.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23941.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27692.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26509.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25020.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16757.6},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20088.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31577.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20987.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30623.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27123.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23121.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26364.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Cc","code_information":[{"code":"351","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16642.97,"maximum":31361.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23777.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27503.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26328.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24849.35},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16642.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19951.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31361.8},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20843.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30413.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26937.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22963.54},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26183.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","code_information":[{"code":"359","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37539.2,"maximum":70738.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53631.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62035.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59384.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56049.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37539.2},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45000.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":70738.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47014.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68600.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60760.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51795.63},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59059.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy With Mcc","code_information":[{"code":"374","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23348.19,"maximum":43997.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33357.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38584.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36935.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34860.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23348.19},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27989.17},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43997.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29241.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42667.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37790.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32215.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36732.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer Without Cc/Mcc","code_information":[{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8740.15,"maximum":16469.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12486.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14443.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13826.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13049.78},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8740.15},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10477.45},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16469.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10946.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15971.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14146.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12059.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13750.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction Without Cc/Mcc","code_information":[{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5938.85,"maximum":11191.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8484.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9814.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9394.88},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8867.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5938.85},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7119.33},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11191.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7437.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10852.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9612.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8194.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9343.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4802.07,"10th_percentile":4802.07,"90th_percentile":4802.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":7450.81,"10th_percentile":7450.81,"90th_percentile":11633.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":8242.47,"10th_percentile":8242.47,"90th_percentile":8242.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures Without Cc/Mcc","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12496.69,"maximum":23548.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17853.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20651.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19768.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18658.61},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12496.69},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14980.69},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23548.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15651.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22836.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20226.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17242.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19660.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4231.85,"10th_percentile":4231.85,"90th_percentile":4231.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Mcc","code_information":[{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36062.13,"maximum":67955.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51521.57},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59594.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57047.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53843.79},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36062.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43230.29},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":67955.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45164.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65900.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58369.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49757.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56735.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","code_information":[{"code":"419","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14910.44,"maximum":28097.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21302.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24640.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23587.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22262.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14910.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17874.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28097.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18674.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27247.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24133.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20573.05},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23458.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","code_information":[{"code":"427","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":78805.46,"maximum":148500.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":112588.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":130230.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124665.22},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":117663.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78805.46},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94469.82},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":148500.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98697.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":144011.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":127552.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108733.77},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123981.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Cc","code_information":[{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12348.22,"maximum":23268.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17641.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20406.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19534.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18436.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12348.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14802.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23268.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15465.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22565.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19986.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17037.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19427.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4756.34,"10th_percentile":4756.34,"90th_percentile":4756.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract With Mcc","code_information":[{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18241.22,"maximum":34373.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26061.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30144.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28856.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27235.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18241.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21867.07},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34373.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22845.56},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33334.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29524.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25168.77},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28698.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Or Infection With Cc","code_information":[{"code":"457","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":65099.16,"maximum":122672.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":93006.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":107580.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":102982.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":97198.53},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65099.16},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78039.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":122672.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81531.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118963.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105367.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89822.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102418.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Cc","code_information":[{"code":"467","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38499.89,"maximum":72548.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55004.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63623.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60904.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57483.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38499.89},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46152.61},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":72548.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48217.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70355.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62315.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53121.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60570.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":3310.84,"10th_percentile":3310.84,"90th_percentile":3310.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","code_information":[{"code":"475","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24843.82,"maximum":46815.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35494.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41055.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39301.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37093.91},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24843.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29782.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46815.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31114.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45400.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40211.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34278.87},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39085.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","code_information":[{"code":"483","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30260.83,"maximum":57023.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":43233.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50007.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47870.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45181.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30260.83},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36275.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":57023.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37899.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55299.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48979.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41753.13},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47608.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","code_information":[{"code":"494","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21904.96,"maximum":41277.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31295.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36199.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34652.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32705.95},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21904.96},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26259.07},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41277.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27434.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40029.68},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35454.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30223.91},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34462.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":14645.32,"10th_percentile":14645.32,"90th_percentile":14645.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures Without Cc/Mcc","code_information":[{"code":"502","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14693.19,"maximum":27687.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20992.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24281.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23243.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21938.17},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14693.19},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17613.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27687.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18401.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26850.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23782.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20273.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23116.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","code_information":[{"code":"511","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22700.81,"maximum":42777.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32432.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37514.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35911.24},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33894.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22700.81},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27213.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42777.13},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28430.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41484.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36743.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.0},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35714.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":1358.33,"10th_percentile":1358.33,"90th_percentile":1358.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion With Cc","code_information":[{"code":"519","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21836.18,"maximum":41147.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31197.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36085.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34543.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32603.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21836.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26176.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41147.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27347.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39903.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35343.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30129.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34354.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","code_information":[{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10418.09,"maximum":19631.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14884.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17216.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16480.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15555.09},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10418.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12488.92},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19631.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13047.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19038.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16862.48},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14374.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16390.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Mcc","code_information":[{"code":"545","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27092.72,"maximum":51053.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38707.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44772.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42858.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40451.71},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27092.72},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32478.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":51053.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33931.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49509.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43851.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37381.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42624.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone Diseases And Arthropathies With Mcc","code_information":[{"code":"553","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14151.71,"maximum":26667.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20218.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23386.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21129.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14151.71},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16964.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26667.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17723.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25861.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22905.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19526.17},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22264.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8776.18,"maximum":16537.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12538.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14503.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13883.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13103.57},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8776.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10520.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16537.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10991.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16037.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14204.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12109.15},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13807.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement Without Cc/Mcc","code_information":[{"code":"572","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12514.16,"maximum":23581.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17878.84},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20680.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19796.6},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18684.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12514.16},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15001.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23581.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15672.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22868.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20255.12},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17266.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19688.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","code_information":[{"code":"580","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18864.58,"maximum":35548.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26951.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31174.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29842.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28166.4},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18864.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22614.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35548.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23626.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34473.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30533.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26028.86},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29679.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers Without Cc/Mcc","code_information":[{"code":"594","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9462.86,"maximum":17831.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13519.48},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15637.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14969.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14128.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9462.86},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11343.81},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17831.69},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11851.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17292.66},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15316.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13056.61},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14887.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cellulitis With Mcc","code_information":[{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15516.33,"maximum":29238.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22168.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25641.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24545.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23167.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15516.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18600.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29238.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19432.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28354.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25114.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21409.04},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24411.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7547.77,"10th_percentile":7547.77,"90th_percentile":7547.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"1 through 10","median_amount":3234.26,"10th_percentile":3234.26,"90th_percentile":3234.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":28872.92,"10th_percentile":28872.92,"90th_percentile":28872.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":20087.8,"10th_percentile":20087.8,"90th_percentile":20087.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc Or Insertion Of","code_information":[{"code":"616","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38071.95,"maximum":71742.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54392.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62916.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":60227.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56844.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38071.95},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45639.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":71742.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47681.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69573.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61622.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52530.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59897.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"624","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13666.99,"maximum":25753.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19525.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22585.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21620.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20405.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13666.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16383.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25753.91},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17116.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24975.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22121.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18857.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21501.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Cc","code_information":[{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9783.82,"maximum":18436.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13978.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16168.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15477.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14608.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9783.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11728.57},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18436.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12253.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17879.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15835.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13499.46},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15392.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6136.26,"10th_percentile":4788.43,"90th_percentile":11417.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis With Mcc","code_information":[{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":51325.18,"maximum":96716.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73327.74},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84817.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81193.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76632.82},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51325.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61527.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":96716.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64280.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93792.93},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83073.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70817.19},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80748.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm Without Cc/Mcc","code_information":[{"code":"658","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16941.0,"maximum":31923.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24203.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27996.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26799.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25294.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16941.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20308.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31923.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21217.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30958.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27420.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23374.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26652.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy With Cc","code_information":[{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19097.11,"maximum":35986.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27283.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31559.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30210.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28513.59},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19097.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22893.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35986.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23917.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34898.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30910.13},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26349.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30044.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures With Cc","code_information":[{"code":"674","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25530.5,"maximum":48109.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36475.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42190.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40387.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38119.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25530.5},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30605.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":48109.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31974.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46655.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41323.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35226.33},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40166.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections With Mcc","code_information":[{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12667.0,"maximum":23869.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18097.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20932.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20038.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18912.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12667.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15184.85},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23869.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15864.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23147.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20502.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17477.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19928.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":5513.03,"10th_percentile":5334.17,"90th_percentile":11511.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":21999.69,"10th_percentile":21999.69,"90th_percentile":21999.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Cc","code_information":[{"code":"699","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11080.76,"maximum":20880.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15830.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18311.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17529.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16544.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11080.76},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13283.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20880.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13877.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20249.25},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17935.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15288.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17432.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":15024.89,"10th_percentile":15024.89,"90th_percentile":15024.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy With Cc/Mcc","code_information":[{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16412.62,"maximum":30927.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23448.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27122.84},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25963.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24505.42},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16412.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19675.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30927.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20555.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29992.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26565.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22645.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25821.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System Without Cc/Mcc","code_information":[{"code":"724","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7158.28,"maximum":13488.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10226.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11829.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11323.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10687.91},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7158.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8581.15},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13488.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8965.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13081.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11586.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9876.81},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11261.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","code_information":[{"code":"735","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14688.82,"maximum":27679.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20985.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24274.17},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23236.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21931.65},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14688.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17608.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27679.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18396.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26842.73},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23774.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20267.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23109.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","code_information":[{"code":"743","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13544.72,"maximum":25523.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19351.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22383.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21426.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20223.41},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13544.72},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16237.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25523.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16963.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24751.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21923.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18688.66},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21309.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15380.03,"10th_percentile":15380.03,"90th_percentile":15380.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System With Mcc","code_information":[{"code":"754","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20105.84,"maximum":37887.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28724.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33226.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31806.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30019.71},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20105.84},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24102.33},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37887.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25180.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36741.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32542.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27741.53},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31631.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","code_information":[{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11698.66,"maximum":22044.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16713.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19332.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18506.53},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17467.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11698.66},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14024.03},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22044.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14651.57},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21378.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18935.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16141.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18405.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":6574.86,"10th_percentile":6574.86,"90th_percentile":6574.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6577.12,"10th_percentile":6577.12,"90th_percentile":6577.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Mcc","code_information":[{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18007.59,"maximum":33933.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25727.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29758.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28486.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26886.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18007.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21587.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33933.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22552.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32907.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29146.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24846.42},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28330.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":45070.67,"10th_percentile":45070.67,"90th_percentile":45070.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14451.95,"10th_percentile":14451.95,"90th_percentile":14451.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13622.86,"10th_percentile":13622.86,"90th_percentile":13622.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neonate With Other Significant Problems","code_information":[{"code":"794","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16112.4,"maximum":30362.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23019.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26626.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25488.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24057.17},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16112.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19315.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30362.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20179.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29444.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26079.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22231.48},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25349.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3308.05,"10th_percentile":3308.05,"90th_percentile":3308.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":4991.67,"10th_percentile":4991.67,"90th_percentile":4991.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":4939.05,"10th_percentile":4939.05,"90th_percentile":4939.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2049.3,"10th_percentile":2049.3,"90th_percentile":2049.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":7802.19,"10th_percentile":7802.19,"90th_percentile":7802.19},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2309.43,"10th_percentile":2309.43,"90th_percentile":2309.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3308.05,"10th_percentile":3308.05,"90th_percentile":3308.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2949.05,"10th_percentile":2949.05,"90th_percentile":2949.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"11","median_amount":3102.0,"10th_percentile":1133.0,"90th_percentile":4653.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2309.43,"10th_percentile":2309.43,"90th_percentile":2309.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","code_information":[{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":43494.42,"maximum":81960.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":62140.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":71877.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68805.41},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64940.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43494.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52139.92},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":81960.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54473.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79482.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70399.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60012.5},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68428.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"810","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11425.73,"maximum":21530.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16323.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18881.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18074.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17059.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11425.73},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13696.85},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21530.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14309.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20879.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18493.42},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15764.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17975.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Cc","code_information":[{"code":"818","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12654.99,"maximum":23846.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18080.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20913.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20019.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18894.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12654.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15170.45},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23846.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15849.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23126.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20483.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17461.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","code_information":[{"code":"826","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":51067.54,"maximum":96231.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":72959.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84392.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":80785.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76248.14},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51067.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61218.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":96231.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63957.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93322.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82656.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70461.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80342.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Mcc","code_information":[{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59933.24,"maximum":112937.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85625.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99043.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94810.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89485.37},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59933.24},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71846.32},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":112937.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75061.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109523.51},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97006.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82694.36},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94290.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","code_information":[{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11030.54,"maximum":20785.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15759.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18228.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17449.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16469.52},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11030.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13223.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20785.81},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13814.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20157.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17853.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15219.66},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17353.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Other Procedures","code_information":[{"code":"850","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":94535.76,"maximum":178142.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":135062.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":156226.04},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":149549.57},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":141149.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94535.76},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113326.88},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":178142.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118397.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":172757.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":153013.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130438.05},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148729.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections Without Mcc","code_information":[{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10894.07,"maximum":20528.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15564.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18003.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17233.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16265.77},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10894.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13059.52},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20528.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13643.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19908.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17632.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15031.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17139.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6324.73,"10th_percentile":6324.73,"90th_percentile":6324.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","code_information":[{"code":"871","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21206.27,"maximum":39960.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30297.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35044.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33546.98},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31662.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21206.27},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25421.5},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39960.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26559.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38752.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34323.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29259.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33363.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":17287.9,"10th_percentile":12560.87,"90th_percentile":33130.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":30602.87,"10th_percentile":30602.87,"90th_percentile":30602.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7173.3,"10th_percentile":7173.3,"90th_percentile":7173.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9076.46,"10th_percentile":9076.46,"90th_percentile":9076.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":10371.38,"10th_percentile":7011.3,"90th_percentile":14265.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":26827.03,"10th_percentile":26827.03,"90th_percentile":26827.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":13236.6,"10th_percentile":6949.16,"90th_percentile":15973.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Psychoses","code_information":[{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15248.87,"maximum":28734.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21785.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25199.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24122.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22767.84},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15248.87},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18279.92},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28734.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19097.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27866.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24681.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21040.0},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23990.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries With Cc","code_information":[{"code":"902","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20900.6,"maximum":39384.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29860.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34539.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33063.42},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31206.35},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20900.6},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25055.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39384.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26176.21},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38194.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33829.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28838.11},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32882.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Injury With Mcc","code_information":[{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17844.93,"maximum":33626.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25494.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29489.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28229.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26643.98},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17844.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21392.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33626.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22349.25},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32610.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28883.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24621.98},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28074.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment Without Cc/Mcc","code_information":[{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7515.26,"maximum":14161.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10736.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12419.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11888.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11220.92},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7515.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9009.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14161.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9412.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13733.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12164.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10369.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11823.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive Burns","code_information":[{"code":"935","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22489.02,"maximum":42378.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32129.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37164.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35576.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33578.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22489.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26959.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42378.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28165.58},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41097.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36400.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31029.78},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35381.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Adrenal And Pituitary Procedures Without Cc/Mcc","code_information":[{"code":"615","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15276.16,"maximum":28786.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21824.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25244.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24165.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22808.59},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15276.16},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18312.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28786.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19132.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27916.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24725.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21077.66},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24033.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19584.01,"maximum":36903.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27979.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32363.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30980.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29240.57},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19584.01},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23476.77},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36903.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24527.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35788.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31698.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27021.52},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30810.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Mcc","code_information":[{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15684.45,"maximum":29555.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22408.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25919.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24811.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23418.21},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15684.45},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18802.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29555.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19643.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28662.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25386.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21641.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24675.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":22713.91,"10th_percentile":22713.91,"90th_percentile":22713.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11424.07,"10th_percentile":11424.07,"90th_percentile":11424.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5202.62,"10th_percentile":5202.62,"90th_percentile":5202.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders Without Cc/Mcc","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8387.53,"maximum":15805.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11983.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13860.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13268.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12523.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8387.53},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10054.74},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":15805.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10504.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15327.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13575.86},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11572.9},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13195.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Neoplasm With Cc","code_information":[{"code":"657","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19978.11,"maximum":37646.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28542.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33015.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31604.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29829.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19978.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23949.21},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37646.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25020.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36508.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32336.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27565.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31430.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy With Mcc","code_information":[{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34074.14,"maximum":64208.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":48681.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56309.57},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53903.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50875.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34074.14},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40847.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64208.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42674.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62267.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55151.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47014.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53607.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures With Mcc","code_information":[{"code":"673","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45868.87,"maximum":86434.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65532.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75801.07},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72561.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68486.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45868.87},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54986.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86434.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57446.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83821.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74242.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63288.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72163.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","code_information":[{"code":"688","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8627.71,"maximum":16257.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12326.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14257.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13648.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12881.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8627.71},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10342.66},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16257.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10805.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15766.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13964.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11904.29},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13573.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Mcc","code_information":[{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18061.08,"maximum":34034.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25803.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29847.03},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28571.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26966.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18061.08},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21651.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34034.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22619.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33005.28},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29233.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24920.23},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28414.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":7900.67,"10th_percentile":6034.03,"90th_percentile":15293.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":22982.29,"10th_percentile":22982.29,"90th_percentile":22982.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":9932.07,"10th_percentile":9932.07,"90th_percentile":9932.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Testes Procedures Without Cc/Mcc","code_information":[{"code":"712","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12005.42,"maximum":22622.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17152.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19839.69},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18991.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17925.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12005.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14391.77},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22622.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15035.77},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21939.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19431.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16564.78},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18887.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Male Reproductive System With Cc","code_information":[{"code":"723","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12474.86,"maximum":23507.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17822.69},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20615.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19734.43},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18626.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12474.86},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14954.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23507.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15623.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22796.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20191.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17212.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19626.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","code_information":[{"code":"734","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23253.21,"maximum":43818.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33221.61},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38427.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36785.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34719.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23253.21},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27875.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43818.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29122.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42493.5},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37637.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32084.19},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36583.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","code_information":[{"code":"742","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20030.51,"maximum":37745.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28617.38},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33101.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31687.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29907.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20030.51},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24012.03},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37745.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25086.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36604.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32420.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27637.59},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31513.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":24385.25,"10th_percentile":24385.25,"90th_percentile":24385.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"750","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16111.31,"maximum":30359.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23018.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26624.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25487.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24055.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16111.31},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19313.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30359.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20178.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29442.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26077.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22229.98},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25347.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Menstrual And Other Female Reproductive System Disorders Without Cc/Mcc","code_information":[{"code":"761","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6228.15,"maximum":11736.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8898.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10292.39},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9852.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9299.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6228.15},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7466.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11736.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7800.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11381.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10080.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8593.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9798.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization Without Cc/Mcc","code_information":[{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10456.3,"maximum":19703.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14938.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17279.67},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16541.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15612.14},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10456.3},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12534.73},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19703.73},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13095.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19108.11},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16924.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14427.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16450.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11917.75,"10th_percentile":11917.75,"90th_percentile":11917.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"1 through 10","median_amount":8498.0,"10th_percentile":8498.0,"90th_percentile":8498.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":17400.0,"10th_percentile":17400.0,"90th_percentile":17400.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13067.0,"10th_percentile":13067.0,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Term Neonate With Major Problems","code_information":[{"code":"793","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45519.52,"maximum":85776.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65033.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75223.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72008.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":67964.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45519.52},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54567.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":85776.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57009.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83183.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73676.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62806.68},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71614.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":915.98,"10th_percentile":915.98,"90th_percentile":915.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5591.91,"10th_percentile":5591.91,"90th_percentile":5591.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":6000.0,"10th_percentile":6000.0,"90th_percentile":6000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":9505.0,"10th_percentile":9505.0,"90th_percentile":9505.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures Without Cc/Mcc","code_information":[{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20839.46,"maximum":39269.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29773.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34438.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32966.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31115.07},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20839.46},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24981.77},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39269.62},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26099.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38082.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33730.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28753.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32786.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13819.83,"maximum":26041.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19744.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22838.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21862.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20634.17},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13819.83},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16566.83},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26041.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17308.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25254.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22368.45},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19068.25},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21742.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6926.89,"10th_percentile":6926.89,"90th_percentile":6926.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. Procedures With Mcc","code_information":[{"code":"817","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24908.23,"maximum":46936.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35586.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":41162.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39403.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37190.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24908.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29859.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46936.76},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31195.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45517.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40315.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34367.74},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39187.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures Without Cc/Mcc","code_information":[{"code":"825","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14731.4,"maximum":27759.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21046.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24344.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23304.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21995.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14731.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17659.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27759.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18449.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26920.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23843.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20326.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23176.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","code_information":[{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5708.5,"maximum":10757.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8155.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9433.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9030.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":8523.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5708.5},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6843.19},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":10757.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7149.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10431.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9239.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7876.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8980.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4485.75,"10th_percentile":4485.75,"90th_percentile":4485.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":7752.3,"10th_percentile":7752.3,"90th_percentile":7752.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Cc","code_information":[{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17809.99,"maximum":33560.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25444.95},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29432.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28174.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26591.82},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17809.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21350.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33560.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22305.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32546.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28826.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24573.78},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28019.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Radiotherapy","code_information":[{"code":"849","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29579.61,"maximum":55739.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42260.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":48882.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46793.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44164.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29579.61},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35459.23},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":55739.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37045.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54054.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47876.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40813.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46536.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections With Mcc","code_information":[{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19909.33,"maximum":37516.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28444.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32901.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31495.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29726.31},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19909.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23866.76},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37516.9},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24934.74},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36382.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32224.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27470.39},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31322.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis With Mv >96 Hours","code_information":[{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":75456.12,"maximum":142188.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":107803.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":124695.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":119366.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":112662.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75456.12},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90454.73},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":142188.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94502.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":137890.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122131.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":104112.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118712.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Organic Disturbances And Intellectual Disability","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17564.36,"maximum":33098.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25094.01},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29026.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27785.7},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26225.07},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17564.36},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21055.67},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33098.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21997.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32097.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28429.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24234.86},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27633.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":5262.83,"10th_percentile":5262.83,"90th_percentile":5262.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":15596.8,"10th_percentile":15596.8,"90th_percentile":15596.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries With Mcc","code_information":[{"code":"901","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45814.28,"maximum":86331.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65454.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75710.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72475.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68404.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45814.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54920.9},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86331.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57378.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83722.17},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74153.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63213.39},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72078.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries Without Cc/Mcc","code_information":[{"code":"909","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14330.75,"maximum":27004.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20474.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23682.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22670.33},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21397.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14330.75},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17179.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27004.68},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17948.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26188.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23195.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19773.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22546.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment With Cc","code_information":[{"code":"920","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10942.11,"maximum":20619.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15632.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18082.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17309.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16337.49},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10942.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13117.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20619.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13704.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19995.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17710.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15097.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17214.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn Without Skin Graft Or Inhalation Injury","code_information":[{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24133.12,"maximum":45476.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34478.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39881.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38177.06},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36032.78},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24133.12},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28930.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45476.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30224.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44101.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39061.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33298.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37967.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare With Cc/Mcc","code_information":[{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12987.95,"maximum":24474.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18555.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21463.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20546.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19392.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12987.95},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15569.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24474.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16266.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23734.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21022.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17920.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20433.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Mcc","code_information":[{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29844.89,"maximum":56239.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":42639.08},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49320.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47212.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44560.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29844.89},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35777.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":56239.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37378.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54539.31},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48306.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41179.23},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46953.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Or Without Other Related Condition","code_information":[{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14166.99,"maximum":26696.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20240.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23411.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22411.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21152.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16983.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26696.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17742.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25889.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22930.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19547.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22288.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lung Transplant","code_information":[{"code":"007","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":141377.33,"maximum":266409.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":201984.27},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":233634.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":223649.95},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":211088.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":141377.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":169479.27},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":266409.7},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":177063.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":258356.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":228830.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":195068.86},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":222424.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Autologous Bone Marrow Transplant Without Cc/Mcc","code_information":[{"code":"017","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59304.42,"maximum":111752.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":84727.58},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98004.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93815.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":88546.49},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59304.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71092.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":111752.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74273.72},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108374.39},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95988.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81826.73},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93301.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","code_information":[{"code":"025","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49636.32,"maximum":93534.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":70914.88},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82027.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78521.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74111.21},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49636.32},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59502.66},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":93534.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62165.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90706.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80340.19},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68486.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78091.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures Without Cc/Mcc","code_information":[{"code":"033","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18153.88,"maximum":34208.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25936.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30000.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28718.28},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27105.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18153.88},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21762.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34208.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22736.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33174.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29383.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25048.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28560.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","code_information":[{"code":"041","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24003.21,"maximum":45231.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34293.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39666.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37971.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35838.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24003.21},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28774.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":45231.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30061.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43864.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38851.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33119.02},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37763.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8173.5,"10th_percentile":8173.5,"90th_percentile":8173.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Mcc","code_information":[{"code":"058","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18662.61,"maximum":35167.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26663.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30841.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29523.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27864.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18662.61},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22372.23},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35167.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23373.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34104.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30206.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25750.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29361.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","code_information":[{"code":"066","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7471.59,"maximum":14079.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10674.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12347.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11819.59},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11155.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7471.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8956.74},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14079.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9357.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13653.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12093.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10309.12},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11754.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":11724.03,"10th_percentile":11724.03,"90th_percentile":11724.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders Without Mcc","code_information":[{"code":"074","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11253.24,"maximum":21205.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16077.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18596.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17801.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16802.04},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11253.24},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13490.08},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21205.47},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14093.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20564.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18214.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15526.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17704.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Mcc","code_information":[{"code":"085","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24802.33,"maximum":46737.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":35434.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40987.35},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39235.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37031.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24802.33},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29732.36},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46737.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31062.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45324.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40144.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34221.63},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39020.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System Without Cc/Mcc","code_information":[{"code":"093","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8693.21,"maximum":16381.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12419.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14366.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13752.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12979.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8693.21},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10421.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16381.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10887.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15886.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14070.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11994.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13676.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Seizures Without Mcc","code_information":[{"code":"101","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9853.68,"maximum":18568.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14077.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16283.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15587.9},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14712.38},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9853.68},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11812.33},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18568.16},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12340.9},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18006.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15948.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13595.86},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15502.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":9562.32,"10th_percentile":9562.32,"90th_percentile":9562.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections With Cc/Mcc","code_information":[{"code":"121","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12699.75,"maximum":23931.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18143.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20987.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20090.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18961.79},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12699.75},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15224.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23931.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15905.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23207.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20555.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17522.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19980.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures Without Cc/Mcc","code_information":[{"code":"138","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9674.65,"maximum":18230.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13822.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15987.93},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15304.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14445.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9674.65},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11597.7},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18230.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12116.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17679.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15659.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13348.83},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15220.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Mcc","code_information":[{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23115.66,"maximum":43558.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33025.09},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38200.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36567.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34513.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23115.66},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27710.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43558.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28950.38},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42242.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37414.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31894.4},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36367.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","code_information":[{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17068.73,"maximum":32164.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24385.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28207.1},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27001.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25485.05},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17068.73},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20461.52},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32164.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21377.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31191.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27627.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23551.0},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26853.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures Without Cc/Mcc","code_information":[{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20897.32,"maximum":39378.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29855.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34534.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33058.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31201.46},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20897.32},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25051.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39378.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26172.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38188.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33823.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28833.59},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32877.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations With Cc","code_information":[{"code":"178","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10654.99,"maximum":20078.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15222.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17608.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16855.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15908.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10654.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12772.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20078.14},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13344.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19471.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17245.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14701.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16763.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8971.46,"10th_percentile":8971.46,"90th_percentile":10914.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Mcc","code_information":[{"code":"186","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17014.14,"maximum":32061.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24307.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28116.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26915.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25403.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17014.14},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20396.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32061.24},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21308.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31092.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27538.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23475.69},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26767.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy With Cc","code_information":[{"code":"194","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8798.01,"maximum":16578.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12569.62},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14539.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13917.89},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13136.17},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8798.01},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10546.81},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16578.86},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11018.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16077.71},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14240.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12139.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13841.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4111.1,"10th_percentile":4111.1,"90th_percentile":4111.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":11244.9,"10th_percentile":11244.9,"90th_percentile":11277.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":1289.19,"10th_percentile":1289.19,"90th_percentile":1289.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":10908.05,"10th_percentile":10908.05,"90th_percentile":10908.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":2534.44,"10th_percentile":2534.44,"90th_percentile":2534.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bronchitis And Asthma With Cc/Mcc","code_information":[{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10602.59,"maximum":19979.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15147.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17521.42},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16772.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15830.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10602.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12710.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19979.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13278.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19375.44},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17161.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14629.19},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16680.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8699.26,"10th_percentile":8699.26,"90th_percentile":8699.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":8417.32,"10th_percentile":8417.32,"90th_percentile":8417.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concomitant Aortic And Mitral Valve Procedures","code_information":[{"code":"212","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":118712.55,"maximum":223700.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":169603.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":196179.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":187795.71},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":177247.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118712.55},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":142309.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":223700.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148677.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":216938.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192145.35},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":163796.57},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":186766.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","code_information":[{"code":"221","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":55023.86,"maximum":103686.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":78612.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90930.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":87044.25},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82155.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55023.86},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65961.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":103686.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68912.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100551.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89060.33},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75920.53},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86567.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","code_information":[{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45729.13,"maximum":86171.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":65332.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":75570.14},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":72340.58},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":68277.44},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45729.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54818.83},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":86171.41},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57271.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83566.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74016.1},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63095.89},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71944.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","code_information":[{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23826.35,"maximum":44898.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34040.45},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":39374.48},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37691.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35574.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23826.35},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28562.38},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":44898.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29840.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43540.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38564.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32875.0},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37485.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement With Mcc","code_information":[{"code":"258","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34302.31,"maximum":64638.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49007.33},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56686.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54264.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51216.23},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34302.31},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41120.66},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64638.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42960.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62684.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55520.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47329.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53966.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","code_information":[{"code":"266","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":66903.74,"maximum":126072.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95584.65},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110562.46},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105837.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99892.92},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66903.74},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80202.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":126072.59},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83791.22},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122261.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108288.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92312.09},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105257.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures Without Mcc","code_information":[{"code":"274","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35935.49,"maximum":67716.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":51340.64},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59385.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56847.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53654.71},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35935.49},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43078.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":67716.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45006.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65669.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58164.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49582.88},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56536.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","code_information":[{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7894.08,"maximum":14875.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11278.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13045.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12487.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11786.53},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7894.08},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9463.21},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14875.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9886.66},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14425.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12777.18},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10892.06},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12419.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":9246.09,"10th_percentile":9246.09,"90th_percentile":9246.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis Without Cc/Mcc","code_information":[{"code":"290","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10149.53,"maximum":19125.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14500.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16772.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16055.92},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15154.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10149.53},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12166.98},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19125.66},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12711.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18547.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16427.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14004.07},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15967.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Cc","code_information":[{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11653.9,"maximum":21960.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16649.8},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19258.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18435.73},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17400.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11653.9},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13970.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21960.46},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14595.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21296.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18862.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16079.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18334.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":8839.66,"10th_percentile":8839.66,"90th_percentile":8839.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13144.07,"maximum":24768.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18778.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21721.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20793.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19625.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13144.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15756.75},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24768.52},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16461.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24019.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21274.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18135.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20679.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":7695.86,"10th_percentile":6398.91,"90th_percentile":11236.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses Without Cc/Mcc","code_information":[{"code":"316","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7446.49,"maximum":14032.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10638.71},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12305.77},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11779.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11118.23},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7446.49},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8926.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14032.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9326.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13607.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12052.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10274.47},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11715.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","code_information":[{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34399.47,"maximum":64821.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49146.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56847.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54417.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51361.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34399.47},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41237.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":64821.93},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43082.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62862.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55678.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47463.51},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54119.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection With Mcc","code_information":[{"code":"332","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39527.18,"maximum":74484.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":56472.06},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":65321.05},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62529.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59017.41},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39527.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47384.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":74484.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49504.42},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72232.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63977.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54538.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62186.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12949.75,"maximum":24402.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18501.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21400.23},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20485.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19335.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12949.75},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15523.8},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24402.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16218.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23664.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20960.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17867.73},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20373.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":19195.64,"10th_percentile":19195.64,"90th_percentile":19195.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Cc","code_information":[{"code":"354","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18366.76,"maximum":34610.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26240.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30352.18},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29055.05},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27423.12},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18366.76},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22017.57},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34610.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23002.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33563.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29728.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25341.99},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28895.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Cc","code_information":[{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10919.18,"maximum":20575.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15600.12},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18044.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17273.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16303.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10919.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13089.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20575.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13675.34},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19953.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17673.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15066.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17178.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4588.05,"10th_percentile":4588.05,"90th_percentile":4588.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Mcc","code_information":[{"code":"377","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19956.28,"maximum":37605.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28511.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32978.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31569.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29796.4},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19956.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23923.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37605.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24993.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36468.6},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32300.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27535.16},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31396.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Mcc","code_information":[{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17273.97,"maximum":32550.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24679.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28546.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27326.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25791.49},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17273.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20707.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32550.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21634.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31566.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27959.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23834.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27176.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses With Mcc","code_information":[{"code":"393","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17459.56,"maximum":32900.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24944.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28852.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27619.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26068.59},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17459.56},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20930.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32900.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21866.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31906.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28259.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24090.26},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27468.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":10716.43,"10th_percentile":10716.43,"90th_percentile":10716.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Cc","code_information":[{"code":"406","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31661.48,"maximum":59662.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45234.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52322.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50086.45},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47273.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31661.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37954.92},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59662.51},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39653.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57858.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51246.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43685.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49811.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","code_information":[{"code":"414","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38892.9,"maximum":73289.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":55565.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":64272.87},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":61526.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58070.38},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38892.9},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46623.75},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":73289.31},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48710.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71073.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62951.14},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53663.44},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61188.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","code_information":[{"code":"422","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15278.34,"maximum":28790.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21828.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25248.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24169.37},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22811.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15278.34},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18315.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":28790.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19134.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27920.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24729.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21080.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24036.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","code_information":[{"code":"430","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":62959.43,"maximum":118639.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":89949.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":104044.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99597.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94003.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62959.43},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75474.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":118639.97},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78851.31},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115053.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101904.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86869.83},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99051.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy With Cc","code_information":[{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9183.38,"maximum":17305.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13120.2},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15176.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14527.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13711.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9183.38},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11008.78},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17305.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11501.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16781.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14864.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12671.0},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14447.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":13416.54,"10th_percentile":13416.54,"90th_percentile":13416.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8559.52,"10th_percentile":8559.52,"90th_percentile":8559.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7997.28,"10th_percentile":7997.28,"90th_percentile":7997.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":15394.82,"10th_percentile":15394.82,"90th_percentile":15394.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":9119.99,"10th_percentile":9119.99,"90th_percentile":9119.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":72943.03,"maximum":137452.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104212.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":120542.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":115391.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":108910.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72943.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87442.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":137452.94},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91354.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":133297.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118063.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100644.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114758.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","code_information":[{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29039.22,"maximum":54721.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":41488.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47989.06},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":45938.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":43358.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29039.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34811.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":54721.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36369.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53067.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47002.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40067.58},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45686.43}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","code_information":[{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21057.8,"maximum":39681.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30085.05},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34799.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33312.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31441.07},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21057.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25243.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39681.06},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26373.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38481.56},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34083.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29055.02},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33129.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":3248.12,"10th_percentile":3248.12,"90th_percentile":3248.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25779.71,"10th_percentile":25779.71,"90th_percentile":25779.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26847.09,"maximum":50590.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38356.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44366.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42470.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40084.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26847.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32183.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50590.32},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33623.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49061.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43454.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37042.93},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42237.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"487","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17098.21,"maximum":32219.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24428.02},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28255.81},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27048.27},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25529.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17098.21},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20496.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32219.65},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21414.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31245.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27674.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23591.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26900.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","code_information":[{"code":"497","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13191.01,"maximum":24856.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18845.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21798.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20867.34},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19695.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13191.01},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15813.02},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24856.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16520.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24105.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21350.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18200.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20752.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":20940.53,"10th_percentile":20940.53,"90th_percentile":20940.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures Without Cc/Mcc","code_information":[{"code":"505","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19572.0,"maximum":36881.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27962.3},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32343.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30961.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29222.64},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19572.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23462.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36881.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24512.26},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35766.36},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31678.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27004.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30791.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","code_information":[{"code":"514","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11160.45,"maximum":21030.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15944.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18443.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17655.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16663.49},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11160.45},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13378.84},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21030.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13977.51},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20394.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18064.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15398.9},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17558.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","code_information":[{"code":"522","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23118.93,"maximum":43565.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":33029.77},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38205.43},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36572.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34518.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23118.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27714.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43565.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28954.49},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42248.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37419.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31898.92},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36372.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":17058.68,"10th_percentile":17058.68,"90th_percentile":17058.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":16973.91,"10th_percentile":16973.91,"90th_percentile":16973.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis With Cc","code_information":[{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14151.71,"maximum":26667.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20218.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23386.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22387.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21129.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14151.71},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16964.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":26667.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17723.8},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25861.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22905.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19526.17},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22264.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Mcc","code_information":[{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21079.64,"maximum":39722.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30116.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34835.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33346.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31473.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21079.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25269.69},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39722.2},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26400.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38521.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34119.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29085.15},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33163.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","code_information":[{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9067.66,"maximum":17086.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12954.87},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14984.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14344.46},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13538.78},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9067.66},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10870.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17086.99},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11356.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16570.47},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14676.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12511.33},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14265.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":11028.45,"10th_percentile":11028.45,"90th_percentile":11028.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":12611.92,"10th_percentile":12611.92,"90th_percentile":12611.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","code_information":[{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16851.48,"maximum":31754.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24075.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27848.09},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26657.97},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25160.68},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16851.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20201.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31754.72},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21105.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30794.82},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27275.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23251.25},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26511.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"575","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19617.85,"maximum":36967.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28027.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32419.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31034.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29291.1},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19617.85},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23517.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":36967.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24569.68},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35850.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31752.99},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27068.21},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30864.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy Without Cc/Mcc","code_information":[{"code":"583","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18825.27,"maximum":35474.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26895.47},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31109.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29780.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28107.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18825.27},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22567.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35474.12},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23577.05},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34401.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30470.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25974.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29617.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Mcc","code_information":[{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18199.73,"maximum":34295.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26001.76},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30076.15},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28790.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27173.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18199.73},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21817.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34295.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22793.61},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33258.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29457.66},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25111.53},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28633.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","code_information":[{"code":"605","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9999.97,"maximum":18843.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14286.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16525.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15819.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14930.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9999.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11987.69},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18843.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12524.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18274.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16185.72},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13797.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15732.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity With Mcc","code_information":[{"code":"619","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31521.75,"maximum":59399.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45034.78},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52091.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49865.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47064.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31521.75},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37787.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59399.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39478.29},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57603.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51020.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43492.91},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49592.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","code_information":[{"code":"627","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14501.05,"maximum":27325.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20717.5},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23963.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22939.74},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21651.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14501.05},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17383.46},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27325.6},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18161.33},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26499.59},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23471.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20008.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22814.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","code_information":[{"code":"641","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8495.61,"maximum":16009.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12137.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14039.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13439.51},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12684.66},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8495.61},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10184.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16009.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10640.03},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15525.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13750.79},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11722.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13365.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":9718.54,"10th_percentile":5108.32,"90th_percentile":11729.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6897.83,"10th_percentile":2180.57,"90th_percentile":8068.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Mcc","code_information":[{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":56729.1,"maximum":106899.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":81048.25},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":93748.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89741.83},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84701.32},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56729.1},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68005.29},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":106899.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71048.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103668.18},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91820.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78273.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89249.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","code_information":[{"code":"661","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11303.46,"maximum":21300.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16149.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18679.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17881.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16877.02},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11303.46},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13550.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":21300.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14156.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20656.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18295.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15596.23},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17783.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Cc","code_information":[{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16943.18,"maximum":31927.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24206.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27999.63},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26803.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25297.6},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16943.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20311.02},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31927.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21219.89},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30962.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27423.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23377.78},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26656.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure With Cc","code_information":[{"code":"683","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9561.11,"maximum":18016.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13659.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15800.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15125.07},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14275.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9561.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11461.59},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18016.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11974.47},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17472.21},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15475.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13192.18},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15042.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12633.63,"10th_percentile":12633.63,"90th_percentile":12633.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":16113.46,"10th_percentile":16113.46,"90th_percentile":16113.46},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7500.54,"10th_percentile":7500.54,"90th_percentile":7500.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":8405.74,"10th_percentile":8405.74,"90th_percentile":15200.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4710.66,"10th_percentile":1419.75,"90th_percentile":11271.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6349.88,"10th_percentile":6349.88,"90th_percentile":6349.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones Without Mcc","code_information":[{"code":"694","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8533.82,"maximum":16081.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12192.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14102.65},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13499.96},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12741.71},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8533.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10230.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16081.02},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10687.88},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15594.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13812.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11774.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13425.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Male Pelvic Procedures Without Cc/Mcc","code_information":[{"code":"708","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16748.86,"maximum":31561.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23928.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27678.5},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26495.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25007.46},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16748.86},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20078.08},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31561.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20976.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30607.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27109.31},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23109.65},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26350.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Male Reproductive System And Other O.R. Procedures For Malignancy Without Cc/Mcc","code_information":[{"code":"716","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16058.91,"maximum":30261.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22943.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26538.31},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25404.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23977.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16058.91},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19250.98},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30261.21},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20112.41},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29346.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25992.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22157.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25264.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammation Of The Male Reproductive System With Mcc","code_information":[{"code":"727","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16188.82,"maximum":30506.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23128.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26753.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25609.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24171.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16188.82},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19406.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30506.01},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20275.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29583.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26202.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22336.92},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25469.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","code_information":[{"code":"738","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16031.61,"maximum":30209.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22904.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26493.21},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25361.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23936.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16031.61},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19218.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30209.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20078.23},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29296.58},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25948.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22120.02},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25222.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures With Cc/Mcc","code_information":[{"code":"746","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18963.92,"maximum":35735.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27093.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31339.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29999.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28314.73},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18963.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22733.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35735.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23750.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34655.15},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30694.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26165.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29835.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infections, Female Reproductive System With Mcc","code_information":[{"code":"757","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15632.05,"maximum":29456.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22333.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25832.91},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24728.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23339.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15632.05},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18739.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29456.85},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19577.81},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28566.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25301.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21568.71},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24593.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","code_information":[{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7147.36,"maximum":13468.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10211.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11811.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11306.67},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10671.61},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7147.36},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8568.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13468.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8951.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13061.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11568.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9861.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11244.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13616.64,"10th_percentile":13616.64,"90th_percentile":13616.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neonates, Died Or Transferred To Another Acute Care Facility","code_information":[{"code":"789","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19674.62,"maximum":37074.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28108.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32513.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31123.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29375.86},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19674.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23585.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37074.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24640.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35953.89},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31844.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27146.54},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30953.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":2089.76,"10th_percentile":2089.76,"90th_percentile":2089.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Cc","code_information":[{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10921.37,"maximum":20580.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15603.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18048.22},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17276.91},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16306.52},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10921.37},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13092.23},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20580.09},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13678.08},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19957.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17677.07},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15069.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17182.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":8021.0,"10th_percentile":8021.0,"90th_percentile":8021.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Mcc","code_information":[{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11781.63,"maximum":22201.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16832.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19469.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18637.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17590.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11781.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14123.49},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22201.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14755.48},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21530.04},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19069.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16255.99},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18535.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5681.99,"10th_percentile":5681.99,"90th_percentile":5681.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coagulation Disorders","code_information":[{"code":"813","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16651.7,"maximum":31378.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23790.1},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27517.94},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26341.93},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24862.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16651.7},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19961.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31378.26},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20854.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30429.74},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26952.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22975.59},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26197.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":14178.0,"10th_percentile":14178.0,"90th_percentile":14178.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":8244.33,"10th_percentile":8244.33,"90th_percentile":8244.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures With Cc","code_information":[{"code":"821","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24438.8,"maximum":46052.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34915.44},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40386.58},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38660.62},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36489.18},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24438.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29296.56},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46052.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30607.5},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44660.07},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39556.06},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33720.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38448.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures With Cc/Mcc","code_information":[{"code":"829","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34497.72,"maximum":65007.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":49286.52},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":57009.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54573.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51508.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34497.72},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41354.92},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":65007.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43205.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63042.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55837.2},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47599.08},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54274.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy With Acute Leukemia As Secondary Diagnosis Or With High Dose Chemotherapy Agent With Mc","code_information":[{"code":"837","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":52448.54,"maximum":98833.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":74932.67},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":86674.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":82970.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78310.09},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52448.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62873.87},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":98833.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65687.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95845.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84891.98},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72367.17},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82515.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","code_information":[{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9296.92,"maximum":17519.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13282.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15363.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14707.13},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13881.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9296.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11144.89},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17519.0},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11643.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16989.42},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15047.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12827.65},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14626.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","code_information":[{"code":"855","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16344.93,"maximum":30800.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23351.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27010.99},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25856.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24404.36},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16344.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19593.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30800.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20470.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29869.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26455.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22552.32},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25714.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness Without Mcc","code_information":[{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9493.42,"maximum":17889.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13563.15},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15688.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15017.99},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14174.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9493.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11380.46},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17889.29},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11889.7},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17348.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15365.83},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13098.78},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14935.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Adjustment Reaction And Psychosocial Dysfunction","code_information":[{"code":"880","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10482.5,"maximum":19753.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14976.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17322.97},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16582.65},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15651.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10482.5},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12566.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19753.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13128.44},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19155.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16966.73},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14463.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16491.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence, Left Ama","code_information":[{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6734.7,"maximum":12690.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9621.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11129.49},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10653.86},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10055.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6734.7},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8073.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12690.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8434.63},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12307.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10900.62},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9292.36},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10595.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12071.7,"10th_percentile":12071.7,"90th_percentile":12071.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries Without Cc/Mcc","code_information":[{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16194.28,"maximum":30516.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23136.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26762.02},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25618.32},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24179.42},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16194.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19413.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30516.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20281.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29593.83},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26211.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22344.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25477.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions Without Mcc","code_information":[{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7274.0,"maximum":13707.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":10392.28},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12020.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11507.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10860.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7274.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8719.87},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":13707.03},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9110.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13292.69},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11773.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10036.48},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11443.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","code_information":[{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":233083.41,"maximum":439219.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":333003.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":385184.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":368723.14},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":348013.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":233083.41},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":279413.99},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":439219.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":291917.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":425942.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":377263.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":321602.58},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":366702.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","code_information":[{"code":"941","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22136.4,"maximum":41713.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31626.04},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36581.74},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35018.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33051.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22136.4},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26536.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41713.56},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27723.95},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40452.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35829.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30543.25},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34826.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":12986.27,"10th_percentile":12986.27,"90th_percentile":12986.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy For Multiple Significant Trauma","code_information":[{"code":"955","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":73483.42,"maximum":138471.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":104984.97},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":121435.78},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":116246.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":109716.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73483.42},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88089.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":138471.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92031.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134285.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118938.54},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101390.56},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":115609.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures With Mcc","code_information":[{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":66826.23,"maximum":125926.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":95473.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":110434.37},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105714.85},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99777.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66826.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80109.45},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":125926.53},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83694.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122119.94},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":108163.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92205.14},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105135.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"983","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18711.74,"maximum":35260.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26733.26},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30922.27},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29600.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27938.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18711.74},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22431.12},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35260.17},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23434.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34194.3},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30286.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25817.98},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29438.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Without Mcc","code_information":[{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8739.06,"maximum":16467.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12485.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14441.82},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13824.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13048.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8739.06},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10476.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16467.77},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10944.92},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15969.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14144.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12057.93},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13748.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":6051.5,"10th_percentile":6051.5,"90th_percentile":6051.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":6796.5,"10th_percentile":6796.5,"90th_percentile":6796.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"959","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32140.74,"maximum":60565.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45919.13},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":53114.51},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50844.61},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47988.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32140.74},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38529.44},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":60565.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40253.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58734.8},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52022.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44346.98},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50565.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition Without Cc/Mcc","code_information":[{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9854.78,"maximum":18570.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14079.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16285.61},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15589.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14714.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9854.78},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11813.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18570.22},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12342.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18008.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15950.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13597.37},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15504.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare Without Cc/Mcc","code_information":[{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6852.6,"maximum":12912.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":9790.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11324.34},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10840.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10231.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6852.6},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8214.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":12912.96},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8582.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12522.62},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11091.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9455.05},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10780.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Cc","code_information":[{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16731.39,"maximum":31528.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23903.96},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27649.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26468.0},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24981.38},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16731.39},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20057.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":31528.43},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20954.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30575.37},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27081.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23085.55},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26322.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":51220.38,"maximum":96519.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":73178.0},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":84644.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":81027.39},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":76476.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51220.38},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61401.59},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":96519.05},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64149.15},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93601.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82904.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70672.58},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80583.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Cc","code_information":[{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10516.35,"maximum":19816.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15024.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17378.9},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16636.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15701.79},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10516.35},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12606.71},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19816.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13170.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19217.84},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17021.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14510.19},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16545.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","code_information":[{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47242.23,"maximum":89022.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":67494.46},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":78070.62},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":74734.2},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":70536.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47242.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56632.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":89022.67},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59166.85},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":86331.63},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76465.16},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65183.63},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74324.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18372.22,"maximum":34620.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26248.19},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30361.2},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29063.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27431.27},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18372.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22024.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34620.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23009.64},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33573.86},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29736.84},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25349.52},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28904.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":9525.22,"10th_percentile":9525.22,"90th_percentile":14436.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":12155.68,"10th_percentile":12155.68,"90th_percentile":12155.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":25349.52,"10th_percentile":25349.52,"90th_percentile":25349.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Cc","code_information":[{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16426.81,"maximum":30954.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23468.81},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27146.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25986.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24526.61},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16426.81},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19692.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30954.48},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20573.18},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30018.77},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26588.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22665.3},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25843.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal And Femoral With Mcc","code_information":[{"code":"353","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31681.13,"maximum":59699.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45262.49},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52354.98},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50117.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47302.6},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31681.13},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37978.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59699.54},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39677.91},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57894.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51278.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43712.83},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49842.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":9526.42,"10th_percentile":9526.42,"90th_percentile":9526.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Mcc","code_information":[{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17378.77,"maximum":32748.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24828.86},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28719.47},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27492.11},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25947.97},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17378.77},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20833.2},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32748.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21765.43},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31758.41},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28128.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23978.79},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27341.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Digestive Malignancy Without Cc/Mcc","code_information":[{"code":"376","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10090.58,"maximum":19014.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14416.31},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16675.3},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15962.66},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15066.09},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10090.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12096.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19014.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12637.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18439.79},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16332.38},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13922.73},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15875.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer Without Mcc","code_information":[{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9331.85,"maximum":17584.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13332.32},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15421.45},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14762.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13933.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9331.85},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11186.77},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17584.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11687.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17053.26},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15104.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12875.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14681.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","code_information":[{"code":"392","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8510.89,"maximum":16037.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12159.42},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14064.76},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13463.69},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12707.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8510.89},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10202.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":16037.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10659.17},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15553.02},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13775.53},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11743.11},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13389.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":7671.76,"10th_percentile":7671.76,"90th_percentile":7671.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":4510.97,"10th_percentile":4510.97,"90th_percentile":4510.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":5430.53,"10th_percentile":5430.53,"90th_percentile":11637.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":11743.11,"10th_percentile":11743.11,"90th_percentile":11743.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8618.16,"10th_percentile":8618.16,"90th_percentile":8618.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Mcc","code_information":[{"code":"405","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59721.45,"maximum":112538.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":85323.39},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":98693.29},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":94475.54},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":89169.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59721.45},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71592.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":112538.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74796.01},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":109136.48},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96663.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82402.14},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93957.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. Without Cc/Mcc","code_information":[{"code":"413","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18127.68,"maximum":34159.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25898.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29957.08},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28676.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27066.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18127.68},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21730.96},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34159.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22703.37},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33126.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29341.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25012.11},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28519.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures With Cc","code_information":[{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18968.29,"maximum":35743.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":27099.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31346.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30006.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28321.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18968.29},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22738.66},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35743.61},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23756.16},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34663.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30701.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26171.96},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29842.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","code_information":[{"code":"429","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":98357.8,"maximum":185344.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":140522.73},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":162542.19},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":155595.79},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":146856.48},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98357.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117908.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":185344.23},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123184.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":179741.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":159199.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":135711.6},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154743.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy With Mcc","code_information":[{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17796.89,"maximum":33536.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":25426.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29410.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28153.55},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26572.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17796.89},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21334.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":33536.25},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22289.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32522.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28805.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24555.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27999.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":33533.17,"10th_percentile":33533.17,"90th_percentile":33533.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":24812.42,"10th_percentile":24812.42,"90th_percentile":24812.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract Without Cc/Mcc","code_information":[{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9031.63,"maximum":17019.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":12903.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14925.32},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14287.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13484.99},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9031.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10826.88},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17019.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11311.35},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16504.64},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14618.39},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12461.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14209.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","code_information":[{"code":"461","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":60294.59,"maximum":113618.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":86142.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":99640.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95382.21},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":90024.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60294.59},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72279.5},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":113618.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75513.83},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":110183.85},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":97591.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83192.95},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":94859.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","code_information":[{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33113.44,"maximum":62398.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":47308.82},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":54721.96},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52383.36},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49441.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33113.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39695.49},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":62398.57},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41471.76},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60512.34},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53596.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45689.09},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52096.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc Or Insertion Of Antibiotic-Eluting","code_information":[{"code":"477","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37713.87,"maximum":71067.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":53881.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62324.44},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59660.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56309.98},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37713.87},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45210.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":71067.55},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47233.4},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68919.27},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61042.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52036.64},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59333.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":15973.78,"10th_percentile":15973.78,"90th_percentile":15973.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Cc","code_information":[{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22828.54,"maximum":43017.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32614.89},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37725.54},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36113.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34084.93},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22828.54},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27366.23},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":43017.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28590.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41717.45},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36949.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31498.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35915.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":20541.05,"10th_percentile":20541.05,"90th_percentile":20541.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":31498.24,"10th_percentile":31498.24,"90th_percentile":31498.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","code_information":[{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19693.18,"maximum":37109.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":28135.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32544.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31153.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29403.57},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19693.18},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23607.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":37109.58},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24664.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35987.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31874.91},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27172.15},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30982.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Cc","code_information":[{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20406.06,"maximum":38452.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":29153.91},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33722.24},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32281.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30467.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20406.06},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24462.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":38452.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25556.84},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37290.54},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33028.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28155.76},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32104.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","code_information":[{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17186.63,"maximum":32386.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":24554.36},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":28401.95},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27188.16},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25661.09},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17186.63},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20602.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":32386.28},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21524.79},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31407.29},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27817.88},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23713.68},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27039.15}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","code_information":[{"code":"521","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31333.97,"maximum":59045.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":44766.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":51781.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":49568.35},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":46784.26},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31333.97},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37562.31},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":59045.35},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39243.13},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57260.49},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50716.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43233.82},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49296.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":14793.56,"10th_percentile":14793.56,"90th_percentile":14793.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis With Mcc","code_information":[{"code":"539","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21503.21,"maximum":40520.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30721.41},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35535.36},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34016.72},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32106.11},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21503.21},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25777.46},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":40520.39},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26930.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39295.52},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34804.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29669.59},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33830.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9128.8,"maximum":17202.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13042.21},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15085.88},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14441.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13630.06},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9128.8},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10943.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":17202.19},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11433.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16682.19},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14775.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12595.68},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14362.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14430.09,"maximum":27191.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20616.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23846.59},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22827.49},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21545.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14430.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17298.4},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27191.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18072.46},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26369.91},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23356.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19910.27},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22702.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","code_information":[{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9776.17,"maximum":18422.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":13967.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16155.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15465.29},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14596.65},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9776.17},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11719.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18422.1},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12243.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17865.23},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15823.49},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13488.92},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15380.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":2063.92,"10th_percentile":2063.92,"90th_percentile":2063.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7067.7,"10th_percentile":7067.7,"90th_percentile":7067.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":14541.0,"10th_percentile":14541.0,"90th_percentile":14541.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37897.27,"maximum":71413.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":54143.43},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62627.53},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59951.08},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":56583.82},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37897.27},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45430.21},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":71413.15},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47463.1},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69254.43},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61339.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52289.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59622.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy With Cc/Mcc","code_information":[{"code":"582","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21032.69,"maximum":39633.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":30049.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34757.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33272.38},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":31403.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21032.69},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25213.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":39633.75},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26341.65},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38435.67},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34043.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29020.38},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33090.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders Without Mcc","code_information":[{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11817.65,"maximum":22269.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16883.75},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19529.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18694.78},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17644.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11817.65},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22269.04},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14800.6},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21595.88},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19127.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16305.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18592.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":10801.14,"10th_percentile":10801.14,"90th_percentile":10801.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":14890.75,"10th_percentile":14890.75,"90th_percentile":14890.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","code_information":[{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16070.92,"maximum":30283.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22960.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26558.16},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25423.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23995.23},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16070.92},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19265.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30283.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20127.45},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29368.4},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26012.01},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22174.24},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25283.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"618","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15483.58,"maximum":29177.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":22121.23},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25587.55},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24494.04},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23118.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15483.58},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18561.29},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":29177.07},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19391.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28295.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25061.36},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21363.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24359.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","code_information":[{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16368.95,"maximum":30845.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23386.14},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27050.68},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25894.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24440.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16368.95},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19622.65},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30845.45},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20500.71},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29913.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26494.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22585.46},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25752.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","code_information":[{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14580.75,"maximum":27475.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20831.35},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24095.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23065.81},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21770.28},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14580.75},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17479.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27475.78},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18261.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26645.22},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23600.05},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20118.14},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22939.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7050.72,"10th_percentile":7050.72,"90th_percentile":7050.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":21400.12,"10th_percentile":21400.12,"90th_percentile":21400.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant","code_information":[{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35256.45,"maximum":66436.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":50370.51},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":58263.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":55773.47},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52640.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35256.45},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42264.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":66436.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44155.69},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64428.53},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57065.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48645.96},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55467.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Cc","code_information":[{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14429.0,"maximum":27189.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20614.55},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23844.79},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22825.76},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21543.71},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14429.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17297.09},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27189.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18071.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26367.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23354.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19908.77},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22700.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Mcc","code_information":[{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31877.64,"maximum":60069.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":45543.24},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":52679.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":50428.4},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":47596.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31877.64},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38214.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":60069.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39924.02},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58254.0},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51596.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43983.96},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50152.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure With Mcc","code_information":[{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16168.08,"maximum":30466.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23099.16},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":26718.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25576.87},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24140.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16168.08},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19381.85},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30466.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20249.14},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29545.95},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26169.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22308.3},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25436.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":21068.59,"10th_percentile":21068.59,"90th_percentile":21068.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":18624.74,"10th_percentile":18624.74,"90th_percentile":18624.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":5468.87,"10th_percentile":4908.18,"90th_percentile":12073.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":14872.23,"10th_percentile":14872.23,"90th_percentile":14872.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones With Mcc","code_information":[{"code":"693","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14677.91,"maximum":27658.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":20970.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24256.12},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23219.52},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21915.35},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14677.91},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17595.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27658.87},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18382.82},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26822.78},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23757.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20252.2},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23092.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Male Pelvic Procedures With Cc/Mcc","code_information":[{"code":"707","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21837.28,"maximum":41149.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31198.68},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36087.41},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34545.18},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32604.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21837.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26177.93},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41149.89},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27349.32},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39905.99},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35345.3},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30130.52},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34355.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Male Reproductive System And Other O.R. Procedures For Malignancy With Cc/Mcc","code_information":[{"code":"715","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24424.6,"maximum":46025.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":34895.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40363.13},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38638.17},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36467.99},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24424.6},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29279.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":46025.42},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30589.73},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44634.14},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39533.09},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33700.45},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38426.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Benign Prostatic Hypertrophy Without Mcc","code_information":[{"code":"726","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7882.07,"maximum":14852.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":11261.03},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":13025.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":12468.94},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":11768.6},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7882.07},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9448.81},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":14852.88},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9871.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14403.9},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12757.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10875.49},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12400.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":3161.46,"10th_percentile":3161.46,"90th_percentile":3161.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","code_information":[{"code":"737","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22495.57,"maximum":42390.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":32139.18},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":37175.28},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":35586.56},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":33587.78},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22495.57},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26967.07},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":42390.37},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28173.78},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41108.97},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36410.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31038.82},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35391.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","code_information":[{"code":"745","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12418.09,"maximum":23400.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":17741.59},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20521.64},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19644.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18541.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12418.09},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14886.46},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":23400.49},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15552.59},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22693.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20099.63},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17134.16},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19536.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System Without Cc/Mcc","code_information":[{"code":"756","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10485.78,"maximum":19759.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14980.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17328.38},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16587.84},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15656.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10485.78},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12570.06},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19759.27},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13132.54},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19161.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16972.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14468.01},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16496.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion With D&C, Aspiration Curettage Or Hysterotomy","code_information":[{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10946.48,"maximum":20627.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15639.11},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18089.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17316.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16344.01},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10946.48},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13122.33},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20627.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13709.53},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20003.87},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17717.71},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15103.67},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17221.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization Without Cc/Mcc","code_information":[{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10467.22,"maximum":19724.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14954.4},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17297.71},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16558.48},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15628.44},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10467.22},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12547.82},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19724.3},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13109.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19128.06},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16942.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14442.4},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16467.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"1 through 10","median_amount":24656.82,"10th_percentile":24656.82,"90th_percentile":24656.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"1 through 10","median_amount":11888.35,"10th_percentile":11888.35,"90th_percentile":12545.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":25018.21,"10th_percentile":25018.21,"90th_percentile":25018.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":22427.73,"10th_percentile":22427.73,"90th_percentile":22427.73},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11316.63,"10th_percentile":11316.63,"90th_percentile":11316.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"1 through 10","median_amount":23498.63,"10th_percentile":23498.63,"90th_percentile":23498.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":13067.0,"10th_percentile":13067.0,"90th_percentile":13198.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Mcc","code_information":[{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12740.14,"maximum":24007.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18201.7},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21053.85},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":20154.09},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19022.1},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12740.14},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15272.53},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":24007.36},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15955.94},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23281.65},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20620.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17578.52},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20043.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","code_information":[{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14803.45,"maximum":27895.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":21149.53},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24463.6},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":23418.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22102.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14803.45},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17745.97},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":27895.44},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18540.06},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27052.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23960.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20425.43},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23289.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders Without Mcc","code_information":[{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10023.99,"maximum":18889.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14321.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16565.25},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15857.31},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":14966.66},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10023.99},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12016.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":18889.08},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12554.19},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18318.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16224.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13830.85},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15770.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":7682.97,"10th_percentile":7682.97,"90th_percentile":7682.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures With Mcc","code_information":[{"code":"820","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":64026.02,"maximum":120649.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":91473.29},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":105806.86},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":101285.1},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":95596.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64026.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76752.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":120649.84},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80187.12},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117002.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103631.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":88341.48},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100729.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures Without C","code_information":[{"code":"828","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18600.38,"maximum":35050.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26574.17},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30738.26},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29424.63},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27771.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18600.38},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22297.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":35050.34},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23295.39},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33990.81},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30106.15},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25664.34},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29263.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia Without Cc/Mcc","code_information":[{"code":"836","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13313.28,"maximum":25087.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":19020.54},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":22001.0},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21060.77},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19877.85},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13313.28},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15959.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25087.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16673.75},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24329.03},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21548.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18369.33},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20945.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","code_information":[{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13290.36,"maximum":25044.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":18987.79},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21963.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":21024.5},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19843.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13290.36},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15932.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":25044.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16645.04},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24287.13},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21511.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18337.7},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20909.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","code_information":[{"code":"854","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21813.26,"maximum":41104.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":31164.37},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":36047.72},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":34507.19},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":32569.03},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21813.26},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26149.13},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":41104.63},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27319.24},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39862.1},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35306.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30097.38},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34318.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"1 through 10","median_amount":11682.18,"10th_percentile":11682.18,"90th_percentile":11682.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"1 through 10","median_amount":30097.38,"10th_percentile":30097.38,"90th_percentile":30097.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness With Mcc","code_information":[{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16356.94,"maximum":30822.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":23368.99},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27030.83},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":25875.64},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":24422.29},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16356.94},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19608.25},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":30822.82},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20485.67},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29891.09},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26474.96},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22568.89},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25733.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Principal Diagnosis Of Mental Illness","code_information":[{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42193.11,"maximum":79508.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":60280.85},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":69726.66},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66746.82},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":62997.87},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42193.11},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50579.95},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":79508.18},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52843.27},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77104.76},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68292.78},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58216.99},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66381.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Mental Disorder Diagnoses","code_information":[{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11691.02,"maximum":22030.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":16702.83},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":19320.11},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18494.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17455.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11691.02},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14014.87},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":22030.4},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14642.0},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21364.46},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18922.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16130.97},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18393.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries With Cc/Mcc","code_information":[{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40099.23,"maximum":75562.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":57289.34},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":66266.4},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":63434.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":59871.53},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40099.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48069.86},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":75562.5},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50220.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73278.35},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64903.68},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55327.91},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63086.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions With Mcc","code_information":[{"code":"915","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18358.03,"maximum":34593.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":26227.92},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":30337.75},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":29041.23},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":27410.08},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18358.03},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22007.1},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":34593.64},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22991.86},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33547.92},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29713.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25329.94},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28882.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","code_information":[{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11110.23,"maximum":20935.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":15873.07},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":18360.33},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":17575.68},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16588.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11110.23},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13318.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":20935.98},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13914.62},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20303.12},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17982.76},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15329.62},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17479.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","code_information":[{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25511.94,"maximum":48074.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":36448.63},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42160.01},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40358.26},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":38091.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25511.94},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30583.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":48074.38},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31951.52},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46621.16},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41293.02},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35200.72},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40137.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Factors Influencing Health Status","code_information":[{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6069.85,"maximum":11437.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":8671.93},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":10030.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9602.12},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":9062.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6069.85},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7276.37},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":11437.95},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7601.97},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11092.2},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9824.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8375.03},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9549.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"1 through 10","median_amount":4900.98,"10th_percentile":4900.98,"90th_percentile":11886.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10267.44,"maximum":19347.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":14668.98},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16967.56},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":16242.44},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":15330.15},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10267.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12308.32},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":19347.83},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12859.09},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18762.98},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16618.64},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14166.75},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16153.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"982","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26839.44,"maximum":50575.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"fee schedule","standard_charge_dollar":38345.22},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":44353.8},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":42458.3},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"fee schedule","standard_charge_dollar":40073.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26839.44},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32174.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"fee schedule","standard_charge_dollar":50575.92},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33614.11},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49047.08},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43441.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37032.39},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42225.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ketorolac tromethamine inj","code_information":[{"code":"0764","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2702.58,"10th_percentile":2702.58,"90th_percentile":2702.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":79.75,"10th_percentile":79.75,"90th_percentile":79.75},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":7539.0,"10th_percentile":7539.0,"90th_percentile":9013.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4090.2,"10th_percentile":185.0,"90th_percentile":11137.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":10522.97,"10th_percentile":10522.97,"90th_percentile":10522.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":6413.92,"10th_percentile":6413.92,"90th_percentile":8756.83},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3959.67,"10th_percentile":3959.67,"90th_percentile":3959.67},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2476.89,"10th_percentile":2476.89,"90th_percentile":2476.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":21308.26,"10th_percentile":21308.26,"90th_percentile":21308.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4322.44,"10th_percentile":4322.44,"90th_percentile":6014.94},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":5916.11,"10th_percentile":4990.18,"90th_percentile":42953.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj, glycopyrrolate, 0.1 mg","code_information":[{"code":"0792","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":22108.88,"10th_percentile":22108.88,"90th_percentile":22108.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Darbepoetin alfa, esrd use","code_information":[{"code":"1482","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"48","median_amount":3004.4,"10th_percentile":1931.4,"90th_percentile":3641.7},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":9009.0,"10th_percentile":8316.0,"90th_percentile":15501.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"19","median_amount":9009.0,"10th_percentile":7623.0,"90th_percentile":9702.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":2789.8,"10th_percentile":2575.2,"90th_percentile":3004.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4742.16,"10th_percentile":4737.65,"90th_percentile":4769.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"58","median_amount":4372.44,"10th_percentile":2380.02,"90th_percentile":4760.0},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2789.8,"10th_percentile":2789.8,"90th_percentile":2789.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":3507.92,"10th_percentile":3008.94,"90th_percentile":3975.4},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2789.8,"10th_percentile":2575.2,"90th_percentile":3004.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"144","median_amount":3235.5,"10th_percentile":2162.5,"90th_percentile":4368.78},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3004.4,"10th_percentile":2789.8,"90th_percentile":3004.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"16","median_amount":12254.84,"10th_percentile":11063.28,"90th_percentile":13385.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"155","median_amount":2789.8,"10th_percentile":2208.0,"90th_percentile":2990.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"30","median_amount":6955.0,"10th_percentile":598.9,"90th_percentile":7490.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1750.0,"10th_percentile":1750.0,"90th_percentile":2000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2576.0,"10th_percentile":2576.0,"90th_percentile":2886.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"75","median_amount":3100.61,"10th_percentile":2495.44,"90th_percentile":3916.11},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":533.6,"10th_percentile":533.6,"90th_percentile":681.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":203.83,"10th_percentile":203.83,"90th_percentile":203.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":81.75,"10th_percentile":81.75,"90th_percentile":170.89},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":248.11,"10th_percentile":248.11,"90th_percentile":248.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1247.11,"10th_percentile":1247.11,"90th_percentile":1247.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":327.0,"10th_percentile":327.0,"90th_percentile":327.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":75.21,"10th_percentile":75.21,"90th_percentile":75.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":227.27,"10th_percentile":227.27,"90th_percentile":289.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":199.76,"10th_percentile":199.76,"90th_percentile":199.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Type A ED Visits","code_information":[{"code":"5022","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":224.8,"10th_percentile":193.07,"90th_percentile":309.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":321.3,"10th_percentile":252.08,"90th_percentile":498.78},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":417.76,"10th_percentile":272.19,"90th_percentile":919.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"14","median_amount":714.75,"10th_percentile":336.0,"90th_percentile":736.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":511.0,"10th_percentile":511.0,"90th_percentile":511.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"1 through 10","median_amount":870.0,"10th_percentile":870.0,"90th_percentile":870.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":224.8,"10th_percentile":224.8,"90th_percentile":224.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":794.75,"10th_percentile":794.75,"90th_percentile":952.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":316.7,"10th_percentile":316.7,"90th_percentile":316.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":466.6,"10th_percentile":466.6,"90th_percentile":466.6},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"20","median_amount":283.13,"10th_percentile":154.56,"90th_percentile":802.24},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":525.24,"10th_percentile":525.24,"90th_percentile":525.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":251.66,"10th_percentile":251.66,"90th_percentile":251.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":213.34,"10th_percentile":213.34,"90th_percentile":213.34},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":281.04,"10th_percentile":274.74,"90th_percentile":615.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":397.79,"10th_percentile":252.77,"90th_percentile":1370.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":661.0,"10th_percentile":661.0,"90th_percentile":1253.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":224.8,"10th_percentile":224.8,"90th_percentile":428.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":902.52,"10th_percentile":477.48,"90th_percentile":1301.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":495.75,"10th_percentile":336.13,"90th_percentile":898.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":189.79,"10th_percentile":171.81,"90th_percentile":443.9},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"23","median_amount":539.52,"10th_percentile":200.0,"90th_percentile":1197.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"17","median_amount":197.38,"10th_percentile":168.78,"90th_percentile":266.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":636.69,"10th_percentile":636.69,"90th_percentile":636.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":202.73,"10th_percentile":202.73,"90th_percentile":202.73},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":594.9,"10th_percentile":594.9,"90th_percentile":1352.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Type A ED Visits","code_information":[{"code":"5023","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"1 through 10","median_amount":5990.0,"10th_percentile":5990.0,"90th_percentile":5990.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"38","median_amount":562.83,"10th_percentile":202.59,"90th_percentile":1158.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"57","median_amount":595.58,"10th_percentile":310.26,"90th_percentile":1288.92},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"73","median_amount":1498.53,"10th_percentile":750.0,"90th_percentile":3523.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"118","median_amount":1467.0,"10th_percentile":812.65,"90th_percentile":3045.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"29","median_amount":546.99,"10th_percentile":262.56,"90th_percentile":1098.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1299.69,"10th_percentile":1299.69,"90th_percentile":1299.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":260.94,"10th_percentile":193.07,"90th_percentile":957.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"11","median_amount":1600.5,"10th_percentile":736.08,"90th_percentile":3804.95},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"41","median_amount":367.43,"10th_percentile":181.48,"90th_percentile":882.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"14","median_amount":811.86,"10th_percentile":498.81,"90th_percentile":1447.6},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"196","median_amount":544.25,"10th_percentile":257.95,"90th_percentile":1316.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1796.76,"10th_percentile":1399.43,"90th_percentile":4043.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":841.5,"10th_percentile":841.5,"90th_percentile":858.93},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1830.19,"10th_percentile":1667.39,"90th_percentile":3221.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"31","median_amount":776.68,"10th_percentile":231.55,"90th_percentile":1047.01},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":928.8,"10th_percentile":351.55,"90th_percentile":1376.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":545.37,"10th_percentile":545.37,"90th_percentile":797.5},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":707.94,"10th_percentile":707.94,"90th_percentile":707.94},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1365.0,"10th_percentile":1365.0,"90th_percentile":1365.0},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1495.78,"10th_percentile":1495.78,"90th_percentile":1495.78},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"32","median_amount":307.68,"10th_percentile":211.42,"90th_percentile":580.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"161","median_amount":660.55,"10th_percentile":358.69,"90th_percentile":1400.21},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"35","median_amount":1820.75,"10th_percentile":1096.68,"90th_percentile":2164.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":290.98,"10th_percentile":214.8,"90th_percentile":711.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"39","median_amount":1477.19,"10th_percentile":643.71,"90th_percentile":3864.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"19","median_amount":1160.54,"10th_percentile":743.17,"90th_percentile":3016.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"171","median_amount":487.37,"10th_percentile":227.7,"90th_percentile":1166.69},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"186","median_amount":1536.7,"10th_percentile":502.82,"90th_percentile":3083.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"89","median_amount":325.53,"10th_percentile":195.43,"90th_percentile":966.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"11","median_amount":783.83,"10th_percentile":222.21,"90th_percentile":863.62},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"49","median_amount":1586.65,"10th_percentile":891.0,"90th_percentile":4475.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Type A ED Visits","code_information":[{"code":"5024","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"1 through 10","median_amount":2178.0,"10th_percentile":2178.0,"90th_percentile":10000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"42","median_amount":934.02,"10th_percentile":297.16,"90th_percentile":1390.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"60","median_amount":1242.45,"10th_percentile":820.96,"90th_percentile":2019.82},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"76","median_amount":3282.66,"10th_percentile":1729.91,"90th_percentile":5554.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"146","median_amount":2350.01,"10th_percentile":1720.03,"90th_percentile":4404.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":980.02,"10th_percentile":360.01,"90th_percentile":1486.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":2254.55,"10th_percentile":2254.55,"90th_percentile":2254.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":928.8,"10th_percentile":928.8,"90th_percentile":1517.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"15","median_amount":3560.65,"10th_percentile":2785.28,"90th_percentile":5483.99},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"28","median_amount":857.05,"10th_percentile":494.55,"90th_percentile":1487.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"15","median_amount":988.38,"10th_percentile":770.86,"90th_percentile":1931.99},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"376","median_amount":1163.75,"10th_percentile":699.2,"90th_percentile":1979.13},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3325.37,"10th_percentile":2117.91,"90th_percentile":7314.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4480.56,"10th_percentile":4480.56,"90th_percentile":4480.56},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3078.58,"10th_percentile":3078.58,"90th_percentile":3535.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"36","median_amount":1172.18,"10th_percentile":412.36,"90th_percentile":2419.78},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":987.6,"10th_percentile":398.26,"90th_percentile":1612.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":1226.31,"10th_percentile":1226.31,"90th_percentile":8591.33},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":4584.25,"10th_percentile":2458.62,"90th_percentile":6584.48},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":648.47,"10th_percentile":255.93,"90th_percentile":1465.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"192","median_amount":1286.35,"10th_percentile":803.21,"90th_percentile":2223.57},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"35","median_amount":4326.0,"10th_percentile":2825.0,"90th_percentile":4455.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1052.69,"10th_percentile":336.65,"90th_percentile":1396.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"54","median_amount":2949.69,"10th_percentile":1863.1,"90th_percentile":6263.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"35","median_amount":2139.94,"10th_percentile":1012.96,"90th_percentile":5056.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"144","median_amount":1140.73,"10th_percentile":625.2,"90th_percentile":2054.93},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"234","median_amount":2655.45,"10th_percentile":1303.63,"90th_percentile":4745.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"79","median_amount":743.99,"10th_percentile":280.62,"90th_percentile":1481.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1078.11,"10th_percentile":1078.11,"90th_percentile":1402.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"24","median_amount":1174.49,"10th_percentile":660.99,"90th_percentile":2065.69},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"14","median_amount":2667.44,"10th_percentile":2036.7,"90th_percentile":5821.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Type A ED Visits","code_information":[{"code":"5025","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"1 through 10","median_amount":9578.5,"10th_percentile":8355.1,"90th_percentile":13233.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1508.16,"10th_percentile":1008.41,"90th_percentile":1844.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"22","median_amount":1919.13,"10th_percentile":1258.03,"90th_percentile":3040.4},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"26","median_amount":4391.32,"10th_percentile":2232.5,"90th_percentile":10896.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"47","median_amount":3928.0,"10th_percentile":1950.0,"90th_percentile":8694.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1094.96,"10th_percentile":707.34,"90th_percentile":2203.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":4749.55,"10th_percentile":4749.55,"90th_percentile":4749.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6027.56,"10th_percentile":4150.23,"90th_percentile":18356.84},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":341.62,"10th_percentile":341.62,"90th_percentile":1143.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"14","median_amount":2291.37,"10th_percentile":1268.23,"90th_percentile":4480.72},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"266","median_amount":1939.04,"10th_percentile":1105.56,"90th_percentile":3719.19},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":6677.34,"10th_percentile":6339.38,"90th_percentile":17848.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"34","median_amount":1958.78,"10th_percentile":1020.23,"90th_percentile":3295.99},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2318.63,"10th_percentile":1450.67,"90th_percentile":2685.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2337.12,"10th_percentile":2337.12,"90th_percentile":2337.12},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":999.24,"10th_percentile":999.24,"90th_percentile":999.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":2776.34,"10th_percentile":2776.34,"90th_percentile":2776.34},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":10374.72,"10th_percentile":10374.72,"90th_percentile":10374.72},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":11210.94,"10th_percentile":11210.94,"90th_percentile":13307.16},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":1138.16,"10th_percentile":284.91,"90th_percentile":1650.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"131","median_amount":2071.32,"10th_percentile":1155.39,"90th_percentile":3888.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"15","median_amount":4794.53,"10th_percentile":3829.0,"90th_percentile":7769.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2067.92,"10th_percentile":1289.67,"90th_percentile":2440.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"15","median_amount":6226.58,"10th_percentile":3026.38,"90th_percentile":7730.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"14","median_amount":5489.76,"10th_percentile":2642.56,"90th_percentile":7139.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"123","median_amount":2082.26,"10th_percentile":1016.62,"90th_percentile":3525.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"85","median_amount":4272.07,"10th_percentile":2268.62,"90th_percentile":9983.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"26","median_amount":1260.32,"10th_percentile":637.65,"90th_percentile":2055.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1913.43,"10th_percentile":1913.43,"90th_percentile":1913.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":2200.23,"10th_percentile":983.87,"90th_percentile":2681.34},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":9233.03,"10th_percentile":7183.23,"90th_percentile":12782.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Critical Care","code_information":[{"code":"5041","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3627.66,"10th_percentile":3627.66,"90th_percentile":3627.66},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":7343.0,"10th_percentile":7343.0,"90th_percentile":7343.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":680.33,"10th_percentile":680.33,"90th_percentile":680.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3374.73,"10th_percentile":3374.73,"90th_percentile":4300.8},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"12","median_amount":4065.09,"10th_percentile":2697.58,"90th_percentile":5112.17},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":12287.64,"10th_percentile":12287.64,"90th_percentile":12287.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":4047.75,"10th_percentile":4047.75,"90th_percentile":4047.75},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3372.57,"10th_percentile":2145.52,"90th_percentile":9037.99},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5410.59,"10th_percentile":5410.59,"90th_percentile":5410.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":12521.7,"10th_percentile":12521.7,"90th_percentile":12521.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"11","median_amount":3451.88,"10th_percentile":1505.87,"90th_percentile":9557.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":8303.49,"10th_percentile":7713.92,"90th_percentile":13349.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":641.72,"10th_percentile":641.72,"90th_percentile":641.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2040.99,"10th_percentile":2040.99,"90th_percentile":2040.99},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma Response with Critical Care","code_information":[{"code":"5045","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":693.76,"10th_percentile":693.76,"90th_percentile":693.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":6336.91,"10th_percentile":6336.91,"90th_percentile":6336.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":5294.27,"10th_percentile":4295.08,"90th_percentile":5313.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":6446.71,"10th_percentile":6446.71,"90th_percentile":6446.71},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":13339.28,"10th_percentile":13339.28,"90th_percentile":13339.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Skin Procedures","code_information":[{"code":"5051","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":484.9,"10th_percentile":484.9,"90th_percentile":484.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":744.38,"10th_percentile":443.13,"90th_percentile":1147.95},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":970.91,"10th_percentile":185.0,"90th_percentile":1383.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"21","median_amount":185.0,"10th_percentile":185.0,"90th_percentile":196.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":221.32,"10th_percentile":221.32,"90th_percentile":221.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":1056.38,"10th_percentile":1056.38,"90th_percentile":1056.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":200.0,"10th_percentile":200.0,"90th_percentile":200.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":218.82,"10th_percentile":210.78,"90th_percentile":468.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":505.01,"10th_percentile":505.01,"90th_percentile":505.01},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"29","median_amount":337.25,"10th_percentile":248.17,"90th_percentile":573.79},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":914.34,"10th_percentile":882.36,"90th_percentile":953.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":565.73,"10th_percentile":315.2,"90th_percentile":647.9},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1812.65,"10th_percentile":1812.65,"90th_percentile":1812.65},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":453.95,"10th_percentile":250.12,"90th_percentile":509.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":440.36,"10th_percentile":384.69,"90th_percentile":624.94},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":902.09,"10th_percentile":875.44,"90th_percentile":906.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":238.21,"10th_percentile":238.21,"90th_percentile":238.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"13","median_amount":962.4,"10th_percentile":861.23,"90th_percentile":1609.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1069.45,"10th_percentile":1069.45,"90th_percentile":1069.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"12","median_amount":355.92,"10th_percentile":319.18,"90th_percentile":738.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"42","median_amount":599.93,"10th_percentile":20.0,"90th_percentile":884.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":238.21,"10th_percentile":210.78,"90th_percentile":464.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":337.78,"10th_percentile":337.78,"90th_percentile":337.78},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"32","median_amount":1279.15,"10th_percentile":921.75,"90th_percentile":2164.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Skin Procedures","code_information":[{"code":"5052","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":491.12,"10th_percentile":491.12,"90th_percentile":491.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2654.0,"10th_percentile":2654.0,"90th_percentile":10681.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1551.89,"10th_percentile":1551.89,"90th_percentile":1551.89},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":250.06,"10th_percentile":250.06,"90th_percentile":250.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1706.02,"10th_percentile":1706.02,"90th_percentile":1706.02},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":931.73,"10th_percentile":438.5,"90th_percentile":2104.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1713.92,"10th_percentile":1713.92,"90th_percentile":1713.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3391.83,"10th_percentile":3391.83,"90th_percentile":3391.83},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":435.12,"10th_percentile":435.12,"90th_percentile":435.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1205.11,"10th_percentile":754.66,"90th_percentile":2200.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1253.98,"10th_percentile":1253.98,"90th_percentile":1253.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":570.61,"10th_percentile":570.61,"90th_percentile":570.61},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1920.55,"10th_percentile":491.12,"90th_percentile":14973.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":662.89,"10th_percentile":662.89,"90th_percentile":662.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1623.16,"10th_percentile":1576.1,"90th_percentile":2019.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Skin Procedures","code_information":[{"code":"5054","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2103.84,"10th_percentile":2103.84,"90th_percentile":2103.84},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5071","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":675.61,"10th_percentile":675.61,"90th_percentile":675.61},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2771.0,"10th_percentile":2771.0,"90th_percentile":2771.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":3499.96,"10th_percentile":3499.96,"90th_percentile":3499.96},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":181.27,"10th_percentile":181.27,"90th_percentile":181.27},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":1352.57,"10th_percentile":1352.57,"90th_percentile":1352.57},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":631.58,"10th_percentile":631.58,"90th_percentile":631.58},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":506.31,"10th_percentile":506.31,"90th_percentile":506.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":649.36,"10th_percentile":648.41,"90th_percentile":1696.15},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2942.0,"10th_percentile":2942.0,"90th_percentile":2942.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":767.87,"10th_percentile":613.36,"90th_percentile":1241.85},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1885.11,"10th_percentile":1413.84,"90th_percentile":5718.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5072","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1593.61,"10th_percentile":1593.61,"90th_percentile":1593.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2500.05,"10th_percentile":2500.05,"90th_percentile":2500.05},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":8867.05,"10th_percentile":8867.05,"90th_percentile":8867.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3594.0,"10th_percentile":3594.0,"90th_percentile":3594.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6204.15,"10th_percentile":6204.15,"90th_percentile":6204.15},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1715.03,"10th_percentile":1715.03,"90th_percentile":1715.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":2285.47,"10th_percentile":2088.46,"90th_percentile":4083.55},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1880.91,"10th_percentile":1880.91,"90th_percentile":1880.91},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1706.79,"10th_percentile":1266.48,"90th_percentile":3551.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5928.0,"10th_percentile":5928.0,"90th_percentile":5928.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":4173.41,"10th_percentile":1616.32,"90th_percentile":9954.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1747.52,"10th_percentile":1747.52,"90th_percentile":1747.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2151.88,"10th_percentile":2151.88,"90th_percentile":2151.88},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":6274.8,"10th_percentile":6274.8,"90th_percentile":6274.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Excision/ Biopsy/ Incision and Drainage","code_information":[{"code":"5073","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":9807.0,"10th_percentile":9807.0,"90th_percentile":9807.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3735.0,"10th_percentile":3735.0,"90th_percentile":3735.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2686.1,"10th_percentile":2686.1,"90th_percentile":2686.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":4068.37,"10th_percentile":3097.75,"90th_percentile":5884.45},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3562.3,"10th_percentile":3562.3,"90th_percentile":3562.3},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":10351.64,"10th_percentile":10351.64,"90th_percentile":10351.64},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2495.63,"10th_percentile":2495.63,"90th_percentile":2495.63},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8958.0,"10th_percentile":8958.0,"90th_percentile":8958.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4379.24,"10th_percentile":4379.24,"90th_percentile":4379.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":8068.0,"10th_percentile":6772.94,"90th_percentile":14668.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3549.21,"10th_percentile":3549.21,"90th_percentile":3549.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5091","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2504.15,"10th_percentile":2504.15,"90th_percentile":2504.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3539.94,"10th_percentile":3539.94,"90th_percentile":3539.94},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6013.8,"10th_percentile":6013.8,"90th_percentile":6013.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3735.0,"10th_percentile":3735.0,"90th_percentile":9224.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":3404.96,"10th_percentile":3404.96,"90th_percentile":3404.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4031.91,"10th_percentile":4031.91,"90th_percentile":4031.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":12186.54,"10th_percentile":12186.54,"90th_percentile":12186.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":31100.61,"10th_percentile":31100.61,"90th_percentile":31100.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3150.7,"10th_percentile":3150.7,"90th_percentile":3150.7},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":11306.15,"10th_percentile":7943.15,"90th_percentile":23432.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":5462.43,"10th_percentile":5462.43,"90th_percentile":5462.43},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5092","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":14592.76,"10th_percentile":14592.76,"90th_percentile":14592.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":7316.92,"10th_percentile":7316.92,"90th_percentile":7316.92},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":18470.0,"10th_percentile":18470.0,"90th_percentile":18470.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9178.5,"10th_percentile":9178.5,"90th_percentile":9178.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":6948.46,"10th_percentile":6948.46,"90th_percentile":6948.46},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":5578.66,"10th_percentile":5578.66,"90th_percentile":5578.66},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":16870.31,"10th_percentile":16870.31,"90th_percentile":16870.31},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Breast/Lymphatic Surgery and Related Procedures","code_information":[{"code":"5094","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":48565.56,"10th_percentile":48565.56,"90th_percentile":48565.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":19532.39,"10th_percentile":19532.39,"90th_percentile":19532.39},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":66804.6,"10th_percentile":66804.6,"90th_percentile":66804.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Strapping and Cast Application","code_information":[{"code":"5101","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":734.49,"10th_percentile":734.49,"90th_percentile":734.49},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":185.0,"10th_percentile":185.0,"90th_percentile":196.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":352.25,"10th_percentile":352.25,"90th_percentile":352.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":553.91,"10th_percentile":553.91,"90th_percentile":553.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":169.33,"10th_percentile":169.33,"90th_percentile":169.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":774.66,"10th_percentile":774.66,"90th_percentile":774.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":352.87,"10th_percentile":352.87,"90th_percentile":352.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":961.61,"10th_percentile":961.61,"90th_percentile":961.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Strapping and Cast Application","code_information":[{"code":"5102","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":185.0,"10th_percentile":185.0,"90th_percentile":185.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1411.47,"10th_percentile":1411.47,"90th_percentile":1625.41},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Musculoskeletal Procedures","code_information":[{"code":"5111","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":610.05,"10th_percentile":610.05,"90th_percentile":610.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2846.72,"10th_percentile":2846.72,"90th_percentile":2846.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":524.4,"10th_percentile":462.8,"90th_percentile":1338.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1713.32,"10th_percentile":1713.32,"90th_percentile":1713.32},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":4869.53,"10th_percentile":4869.53,"90th_percentile":4869.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1400.11,"10th_percentile":1400.11,"90th_percentile":1400.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":610.05,"10th_percentile":610.05,"90th_percentile":610.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Musculoskeletal Procedures","code_information":[{"code":"5112","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3388.0,"10th_percentile":2824.4,"90th_percentile":3388.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":1761.12,"10th_percentile":1594.08,"90th_percentile":2430.78},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1484.12,"10th_percentile":1484.12,"90th_percentile":3042.54},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1031.6,"10th_percentile":1031.6,"90th_percentile":1031.6},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1441.88,"10th_percentile":1272.43,"90th_percentile":3423.76},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8715.29,"10th_percentile":8715.29,"90th_percentile":8715.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1499.59,"10th_percentile":1499.59,"90th_percentile":1499.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4335.53,"10th_percentile":4335.53,"90th_percentile":4335.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1813.57,"10th_percentile":1813.57,"90th_percentile":3300.27},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"11","median_amount":4297.53,"10th_percentile":1747.4,"90th_percentile":6500.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1680.55,"10th_percentile":1680.55,"90th_percentile":1717.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2515.88,"10th_percentile":2515.88,"90th_percentile":2515.88},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":7180.39,"10th_percentile":7180.39,"90th_percentile":7180.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Musculoskeletal Procedures","code_information":[{"code":"5113","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2722.22,"10th_percentile":2722.22,"90th_percentile":2722.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4618.58,"10th_percentile":3396.78,"90th_percentile":5970.34},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":9784.01,"10th_percentile":4821.0,"90th_percentile":11019.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"14","median_amount":4025.58,"10th_percentile":3735.0,"90th_percentile":7370.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":17592.5,"10th_percentile":17592.5,"90th_percentile":17592.5},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2731.12,"10th_percentile":2731.12,"90th_percentile":9452.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3180.24,"10th_percentile":3180.24,"90th_percentile":3180.24},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"18","median_amount":3988.98,"10th_percentile":2253.72,"90th_percentile":4923.61},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2472.2,"10th_percentile":2472.2,"90th_percentile":3937.17},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2751.0,"10th_percentile":2751.0,"90th_percentile":2751.0},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"17","median_amount":2945.29,"10th_percentile":2545.64,"90th_percentile":4091.35},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":8991.22,"10th_percentile":8657.0,"90th_percentile":15193.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2722.22,"10th_percentile":2722.22,"90th_percentile":2722.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":11025.45,"10th_percentile":10949.51,"90th_percentile":15542.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":11022.71,"10th_percentile":9904.16,"90th_percentile":14645.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":3487.83,"10th_percentile":2588.2,"90th_percentile":4082.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"18","median_amount":9767.8,"10th_percentile":7482.34,"90th_percentile":14541.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8099.41,"10th_percentile":8099.41,"90th_percentile":8099.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":12059.13,"10th_percentile":9796.31,"90th_percentile":18468.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Musculoskeletal Procedures","code_information":[{"code":"5114","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":10440.26,"10th_percentile":10440.26,"90th_percentile":10440.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":11043.61,"10th_percentile":9170.74,"90th_percentile":13296.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"15","median_amount":5418.45,"10th_percentile":4929.8,"90th_percentile":7379.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1974.29,"10th_percentile":1974.29,"90th_percentile":1974.29},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":6227.14,"10th_percentile":6227.14,"90th_percentile":6227.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":23826.74,"10th_percentile":23826.74,"90th_percentile":23826.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":18942.47,"10th_percentile":18942.47,"90th_percentile":18942.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":5244.24,"10th_percentile":5078.23,"90th_percentile":6944.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"12","median_amount":15755.3,"10th_percentile":12739.73,"90th_percentile":18184.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1623.43,"10th_percentile":1623.43,"90th_percentile":1623.43},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":18965.59,"10th_percentile":18965.59,"90th_percentile":25943.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Musculoskeletal Procedures","code_information":[{"code":"5115","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13968.32,"10th_percentile":13968.32,"90th_percentile":13968.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":10034.93,"10th_percentile":10034.93,"90th_percentile":10034.93},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":13233.51,"10th_percentile":12533.87,"90th_percentile":15512.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":14014.4,"10th_percentile":12175.02,"90th_percentile":20824.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12816.1,"10th_percentile":12816.1,"90th_percentile":12816.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11164.77,"10th_percentile":11164.77,"90th_percentile":11164.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":9029.1,"10th_percentile":8478.0,"90th_percentile":10792.15},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"11","median_amount":9462.94,"10th_percentile":8551.9,"90th_percentile":10060.63},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":8069.28,"10th_percentile":7657.32,"90th_percentile":9486.03},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":8287.58,"10th_percentile":8287.58,"90th_percentile":8287.58},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":35735.78,"10th_percentile":35735.78,"90th_percentile":38134.06},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":33724.29,"10th_percentile":33724.29,"90th_percentile":33724.29},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":12793.12,"10th_percentile":12793.12,"90th_percentile":12793.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"47","median_amount":9086.82,"10th_percentile":8131.68,"90th_percentile":10328.02},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":37849.64,"10th_percentile":37849.64,"90th_percentile":37849.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":27188.27,"10th_percentile":26874.71,"90th_percentile":36759.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":27763.21,"10th_percentile":26961.89,"90th_percentile":38273.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"25","median_amount":9323.4,"10th_percentile":8243.4,"90th_percentile":10762.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"19","median_amount":26598.94,"10th_percentile":22056.19,"90th_percentile":28879.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11925.49,"10th_percentile":11925.49,"90th_percentile":11925.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10127.09,"10th_percentile":10127.09,"90th_percentile":10127.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":7944.12,"10th_percentile":7944.12,"90th_percentile":7944.12},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":29524.34,"10th_percentile":29524.34,"90th_percentile":29524.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 6 Musculoskeletal Procedures","code_information":[{"code":"5116","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":18772.36,"10th_percentile":18772.36,"90th_percentile":18772.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":15652.07,"10th_percentile":15652.07,"90th_percentile":15652.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":11157.91,"10th_percentile":11157.91,"90th_percentile":11157.91},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":9218.17,"10th_percentile":9218.17,"90th_percentile":9218.17},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":10799.01,"10th_percentile":10451.83,"90th_percentile":13584.72},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13664.74,"10th_percentile":13664.74,"90th_percentile":13664.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":32773.47,"10th_percentile":32773.47,"90th_percentile":32773.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":11834.98,"10th_percentile":11834.98,"90th_percentile":14567.55},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":33388.51,"10th_percentile":33388.51,"90th_percentile":37091.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":8782.48,"10th_percentile":8782.48,"90th_percentile":8782.48},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":47345.71,"10th_percentile":47345.71,"90th_percentile":47345.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 ENT Procedures","code_information":[{"code":"5162","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":566.72,"10th_percentile":566.72,"90th_percentile":566.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":12.6,"10th_percentile":12.6,"90th_percentile":12.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Vascular Procedures","code_information":[{"code":"5181","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":646.9,"10th_percentile":646.9,"90th_percentile":755.93},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3729.04,"10th_percentile":3729.04,"90th_percentile":3729.04},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Vascular Procedures","code_information":[{"code":"5182","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2296.76,"10th_percentile":2296.76,"90th_percentile":2296.76},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":917.05,"10th_percentile":917.05,"90th_percentile":917.05},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":5217.34,"10th_percentile":5217.34,"90th_percentile":5217.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Vascular Procedures","code_information":[{"code":"5183","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2374.34,"10th_percentile":2374.34,"90th_percentile":2374.34},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3357.72,"10th_percentile":3357.72,"90th_percentile":3357.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":17270.0,"10th_percentile":17270.0,"90th_percentile":17270.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":2388.67,"10th_percentile":2388.67,"90th_percentile":2388.67},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2729.92,"10th_percentile":2729.92,"90th_percentile":2729.92},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5124.71,"10th_percentile":5124.71,"90th_percentile":5124.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3048.84,"10th_percentile":3048.84,"90th_percentile":3048.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3124.87,"10th_percentile":2185.76,"90th_percentile":5883.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":12802.26,"10th_percentile":12802.26,"90th_percentile":12802.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":16162.07,"10th_percentile":16162.07,"90th_percentile":16162.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4646.49,"10th_percentile":3277.16,"90th_percentile":7414.41},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":15932.18,"10th_percentile":15932.18,"90th_percentile":17688.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2595.95,"10th_percentile":2595.95,"90th_percentile":2595.95},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Vascular Procedures","code_information":[{"code":"5184","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":9097.83,"10th_percentile":9097.83,"90th_percentile":9097.83},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":6072.52,"10th_percentile":6072.52,"90th_percentile":6072.52},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Blood Product Exchange and Related Services","code_information":[{"code":"5241","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":562.49,"10th_percentile":547.95,"90th_percentile":822.21},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":950.58,"10th_percentile":655.27,"90th_percentile":1283.23},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1856.59,"10th_percentile":1856.59,"90th_percentile":1856.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":891.11,"10th_percentile":623.08,"90th_percentile":892.16},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":623.88,"10th_percentile":523.12,"90th_percentile":1031.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3494.74,"10th_percentile":3494.74,"90th_percentile":3494.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Upper GI Procedures","code_information":[{"code":"5301","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1124.22,"10th_percentile":1124.22,"90th_percentile":1124.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1517.96,"10th_percentile":1384.14,"90th_percentile":2574.26},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3335.0,"10th_percentile":3295.0,"90th_percentile":5002.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2512.81,"10th_percentile":2148.24,"90th_percentile":2654.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1332.12,"10th_percentile":1332.12,"90th_percentile":1332.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3428.14,"10th_percentile":3428.14,"90th_percentile":3428.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":7036.74,"10th_percentile":7036.74,"90th_percentile":7036.74},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1115.32,"10th_percentile":1115.32,"90th_percentile":1124.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1377.81,"10th_percentile":1377.81,"90th_percentile":1377.81},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"47","median_amount":1526.04,"10th_percentile":1274.26,"90th_percentile":4544.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1537.54,"10th_percentile":1537.54,"90th_percentile":1537.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1659.03,"10th_percentile":1385.64,"90th_percentile":3440.8},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":4963.36,"10th_percentile":4963.36,"90th_percentile":4963.36},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1330.93,"10th_percentile":1330.93,"90th_percentile":1330.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"27","median_amount":1354.54,"10th_percentile":553.43,"90th_percentile":1770.79},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":4761.0,"10th_percentile":4761.0,"90th_percentile":4761.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1716.78,"10th_percentile":1560.58,"90th_percentile":7169.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4362.97,"10th_percentile":4362.97,"90th_percentile":6549.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":1491.96,"10th_percentile":1377.54,"90th_percentile":2892.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"11","median_amount":3742.43,"10th_percentile":3142.56,"90th_percentile":7602.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1268.68,"10th_percentile":1259.78,"90th_percentile":2511.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1400.0,"10th_percentile":1171.41,"90th_percentile":3200.32},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Upper GI Procedures","code_information":[{"code":"5302","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4464.58,"10th_percentile":4464.58,"90th_percentile":4464.58},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6778.04,"10th_percentile":6778.04,"90th_percentile":6778.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":1731.1,"10th_percentile":1625.6,"90th_percentile":3493.65},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":11320.69,"10th_percentile":11320.69,"90th_percentile":11320.69},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1759.68,"10th_percentile":1383.13,"90th_percentile":3316.91},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7141.5,"10th_percentile":7141.5,"90th_percentile":7141.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1639.02,"10th_percentile":1534.09,"90th_percentile":3136.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":9601.86,"10th_percentile":7059.06,"90th_percentile":10409.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Lower GI Procedures","code_information":[{"code":"5311","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1251.88,"10th_percentile":1251.88,"90th_percentile":1260.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1726.51,"10th_percentile":1687.57,"90th_percentile":2529.51},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3335.0,"10th_percentile":3121.29,"90th_percentile":3335.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"16","median_amount":2654.0,"10th_percentile":2654.0,"90th_percentile":2815.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1148.59,"10th_percentile":1148.59,"90th_percentile":1148.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1397.49,"10th_percentile":1397.49,"90th_percentile":1397.49},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"29","median_amount":1580.39,"10th_percentile":1490.23,"90th_percentile":2658.8},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1543.0,"10th_percentile":1543.0,"90th_percentile":1543.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1612.85,"10th_percentile":1530.21,"90th_percentile":1645.54},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2255.01,"10th_percentile":2255.01,"90th_percentile":2255.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1505.73,"10th_percentile":1505.73,"90th_percentile":1505.73},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1323.82,"10th_percentile":1323.82,"90th_percentile":1323.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"21","median_amount":1531.83,"10th_percentile":1379.61,"90th_percentile":1702.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":4761.0,"10th_percentile":4761.0,"90th_percentile":4761.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4847.35,"10th_percentile":3090.81,"90th_percentile":5470.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5138.32,"10th_percentile":5138.32,"90th_percentile":5138.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1469.36,"10th_percentile":1343.62,"90th_percentile":1660.89},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"34","median_amount":4266.02,"10th_percentile":4083.96,"90th_percentile":4795.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1251.88,"10th_percentile":1251.88,"90th_percentile":1251.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1783.3,"10th_percentile":1783.3,"90th_percentile":1783.3},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Lower GI Procedures","code_information":[{"code":"5312","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2511.66,"10th_percentile":2511.66,"90th_percentile":2599.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2023.65,"10th_percentile":1539.4,"90th_percentile":2691.09},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"22","median_amount":4106.0,"10th_percentile":3594.0,"90th_percentile":6158.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"37","median_amount":3388.0,"10th_percentile":3388.0,"90th_percentile":5082.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1322.63,"10th_percentile":1322.63,"90th_percentile":1322.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":6604.73,"10th_percentile":6604.73,"90th_percentile":10000.71},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1251.88,"10th_percentile":1251.88,"90th_percentile":1251.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2141.42,"10th_percentile":1619.03,"90th_percentile":6022.25},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"72","median_amount":1896.94,"10th_percentile":1677.28,"90th_percentile":3106.66},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2238.02,"10th_percentile":2238.02,"90th_percentile":2238.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1543.0,"10th_percentile":1543.0,"90th_percentile":1543.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1994.93,"10th_percentile":1689.15,"90th_percentile":4940.59},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1260.78,"10th_percentile":1260.78,"90th_percentile":1260.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":1957.22,"10th_percentile":1957.22,"90th_percentile":1957.22},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1314.47,"10th_percentile":1314.47,"90th_percentile":1314.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"57","median_amount":1885.9,"10th_percentile":1575.0,"90th_percentile":2943.61},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":4761.0,"10th_percentile":4761.0,"90th_percentile":7141.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"12","median_amount":5118.56,"10th_percentile":4727.99,"90th_percentile":5504.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":5181.93,"10th_percentile":4835.4,"90th_percentile":9976.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"28","median_amount":2060.56,"10th_percentile":1667.26,"90th_percentile":2606.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"58","median_amount":5050.32,"10th_percentile":4544.45,"90th_percentile":7555.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1251.88,"10th_percentile":1251.88,"90th_percentile":1251.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2666.22,"10th_percentile":2666.22,"90th_percentile":2666.22},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":6322.57,"10th_percentile":6322.57,"90th_percentile":6322.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Lower GI Procedures","code_information":[{"code":"5313","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3470.6,"10th_percentile":3470.6,"90th_percentile":3470.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":14326.57,"10th_percentile":14326.57,"90th_percentile":14326.57},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":3211.34,"10th_percentile":2731.21,"90th_percentile":8062.82},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2893.22,"10th_percentile":2893.22,"90th_percentile":2893.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4848.37,"10th_percentile":4848.37,"90th_percentile":4848.37},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":12877.85,"10th_percentile":12877.85,"90th_percentile":12877.85},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3046.83,"10th_percentile":1931.04,"90th_percentile":4299.2},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7564.0,"10th_percentile":7564.0,"90th_percentile":7564.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":6486.77,"10th_percentile":6486.77,"90th_percentile":6486.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":10488.52,"10th_percentile":10488.52,"90th_percentile":10488.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":6176.5,"10th_percentile":6176.5,"90th_percentile":6176.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":8957.58,"10th_percentile":8957.58,"90th_percentile":8957.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2884.32,"10th_percentile":2884.32,"90th_percentile":2884.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5341","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":6278.7,"10th_percentile":6278.7,"90th_percentile":6278.7},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5428.5,"10th_percentile":5428.5,"90th_percentile":5428.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4156.2,"10th_percentile":4156.2,"90th_percentile":4156.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":3294.12,"10th_percentile":3056.52,"90th_percentile":6760.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3842.1,"10th_percentile":3842.1,"90th_percentile":3842.1},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3174.22,"10th_percentile":3174.22,"90th_percentile":3480.01},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":9303.45,"10th_percentile":9303.45,"90th_percentile":9303.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Abdominal/Peritoneal/Biliary and Related Procedures","code_information":[{"code":"5342","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":2813.9,"10th_percentile":2813.9,"90th_percentile":2813.9},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":7601.43,"10th_percentile":7601.43,"90th_percentile":7601.43},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":15205.23,"10th_percentile":15205.23,"90th_percentile":15970.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5566.58,"10th_percentile":5566.58,"90th_percentile":6741.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":5271.12,"10th_percentile":5271.12,"90th_percentile":5271.12},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6462.0,"10th_percentile":5330.2,"90th_percentile":10183.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"18","median_amount":7366.0,"10th_percentile":4862.73,"90th_percentile":11141.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5048.97,"10th_percentile":5048.97,"90th_percentile":5048.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":27802.14,"10th_percentile":27802.14,"90th_percentile":27802.14},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6440.52,"10th_percentile":4568.36,"90th_percentile":9096.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":6130.32,"10th_percentile":6130.32,"90th_percentile":6130.32},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"42","median_amount":5213.16,"10th_percentile":3055.86,"90th_percentile":7211.14},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":12777.29,"10th_percentile":12777.29,"90th_percentile":12777.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4300.69,"10th_percentile":4300.69,"90th_percentile":4300.69},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4725.96,"10th_percentile":4725.96,"90th_percentile":4725.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1161.49,"10th_percentile":1161.49,"90th_percentile":1161.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"12","median_amount":4656.17,"10th_percentile":4244.83,"90th_percentile":7667.95},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":16813.32,"10th_percentile":16000.41,"90th_percentile":17672.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3979.5,"10th_percentile":3979.5,"90th_percentile":3979.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":13720.78,"10th_percentile":12768.18,"90th_percentile":17625.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":13535.24,"10th_percentile":13535.24,"90th_percentile":23506.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4977.6,"10th_percentile":4977.6,"90th_percentile":5197.26},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"36","median_amount":13566.31,"10th_percentile":10446.23,"90th_percentile":16887.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5868.23,"10th_percentile":5868.23,"90th_percentile":6831.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":5996.16,"10th_percentile":5996.16,"90th_percentile":5996.16},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":20860.64,"10th_percentile":20860.64,"90th_percentile":20860.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":7727.59,"10th_percentile":7727.59,"90th_percentile":7727.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Laparoscopy and Related Services","code_information":[{"code":"5362","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":11781.26,"10th_percentile":11781.26,"90th_percentile":11781.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":7609.0,"10th_percentile":7608.99,"90th_percentile":9442.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":6995.58,"10th_percentile":6995.58,"90th_percentile":6995.58},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":37393.04,"10th_percentile":37393.04,"90th_percentile":37393.04},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":5859.6,"10th_percentile":5859.6,"90th_percentile":5859.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":17314.0,"10th_percentile":17314.0,"90th_percentile":25971.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":21964.34,"10th_percentile":21964.34,"90th_percentile":21964.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"13","median_amount":19694.63,"10th_percentile":17767.76,"90th_percentile":25617.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":10103.86,"10th_percentile":10103.86,"90th_percentile":10103.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Urology and Related Services","code_information":[{"code":"5371","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":896.09,"10th_percentile":896.09,"90th_percentile":2752.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1589.31,"10th_percentile":1589.31,"90th_percentile":1589.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":27524.37,"10th_percentile":27524.37,"90th_percentile":27524.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Urology and Related Services","code_information":[{"code":"5373","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":237.5,"10th_percentile":237.5,"90th_percentile":237.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":209.53,"10th_percentile":209.53,"90th_percentile":209.53},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":2749.94,"10th_percentile":2749.94,"90th_percentile":2749.94},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":142.18,"10th_percentile":142.18,"90th_percentile":142.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Gynecologic Procedures","code_information":[{"code":"5411","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":276.6,"10th_percentile":247.68,"90th_percentile":319.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":563.27,"10th_percentile":500.82,"90th_percentile":820.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":413.54,"10th_percentile":247.68,"90th_percentile":9884.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":295.45,"10th_percentile":260.06,"90th_percentile":657.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":344.25,"10th_percentile":344.25,"90th_percentile":344.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":950.3,"10th_percentile":950.3,"90th_percentile":950.3},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":223.84,"10th_percentile":223.84,"90th_percentile":247.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":247.68,"10th_percentile":247.68,"90th_percentile":340.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"30","median_amount":260.06,"10th_percentile":260.06,"90th_percentile":355.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1283.1,"10th_percentile":1237.63,"90th_percentile":1391.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":247.68,"10th_percentile":247.68,"90th_percentile":247.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":506.23,"10th_percentile":404.98,"90th_percentile":1305.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":534.75,"10th_percentile":534.75,"90th_percentile":3379.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"44","median_amount":500.53,"10th_percentile":247.68,"90th_percentile":926.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":395.51,"10th_percentile":253.68,"90th_percentile":586.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2518.56,"10th_percentile":2518.56,"90th_percentile":2518.56},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Gynecologic Procedures","code_information":[{"code":"5412","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2618.85,"10th_percentile":2618.85,"90th_percentile":2618.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2113.73,"10th_percentile":2113.73,"90th_percentile":2113.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Gynecologic Procedures","code_information":[{"code":"5413","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":5977.2,"10th_percentile":5977.2,"90th_percentile":5977.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1568.65,"10th_percentile":1568.65,"90th_percentile":1568.65},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Gynecologic Procedures","code_information":[{"code":"5414","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2723.2,"10th_percentile":2723.2,"90th_percentile":2723.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2956.9,"10th_percentile":2956.9,"90th_percentile":2956.9},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":5773.5,"10th_percentile":5773.5,"90th_percentile":5773.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":3388.0,"10th_percentile":1790.57,"90th_percentile":3594.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":12397.57,"10th_percentile":12397.57,"90th_percentile":12397.57},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2696.65,"10th_percentile":2696.65,"90th_percentile":2696.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":11322.96,"10th_percentile":11322.96,"90th_percentile":11322.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1999.77,"10th_percentile":1999.77,"90th_percentile":1999.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1906.53,"10th_percentile":1906.53,"90th_percentile":1906.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3035.91,"10th_percentile":2773.29,"90th_percentile":3499.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7564.0,"10th_percentile":7564.0,"90th_percentile":7564.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":10177.41,"10th_percentile":10177.41,"90th_percentile":10177.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":8196.66,"10th_percentile":8196.66,"90th_percentile":13041.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3923.53,"10th_percentile":3923.53,"90th_percentile":5060.03},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"12","median_amount":9323.31,"10th_percentile":7564.33,"90th_percentile":11819.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2982.15,"10th_percentile":2982.15,"90th_percentile":2982.15,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Gynecologic Procedures","code_information":[{"code":"5415","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":4428.0,"10th_percentile":4428.0,"90th_percentile":4428.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3277.48,"10th_percentile":3277.48,"90th_percentile":3277.48},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":9824.0,"10th_percentile":9824.0,"90th_percentile":9824.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":8565.64,"10th_percentile":8565.64,"90th_percentile":8565.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":9181.12,"10th_percentile":9181.12,"90th_percentile":12857.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nerve Procedures","code_information":[{"code":"5431","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1707.1,"10th_percentile":1707.1,"90th_percentile":1707.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2094.38,"10th_percentile":1701.02,"90th_percentile":4108.08},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4106.0,"10th_percentile":4066.0,"90th_percentile":5420.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"15","median_amount":3388.0,"10th_percentile":3032.92,"90th_percentile":3594.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":5504.65,"10th_percentile":5504.65,"90th_percentile":5839.71},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1707.1,"10th_percentile":1707.1,"90th_percentile":2560.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1473.14,"10th_percentile":1367.04,"90th_percentile":4048.92},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"20","median_amount":1759.05,"10th_percentile":1636.24,"90th_percentile":3477.62},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":3170.0,"10th_percentile":3170.0,"90th_percentile":3170.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1707.1,"10th_percentile":1707.1,"90th_percentile":1707.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":7896.85,"10th_percentile":7896.85,"90th_percentile":7896.85},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":780.5,"10th_percentile":780.5,"90th_percentile":780.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"28","median_amount":2268.93,"10th_percentile":1644.16,"90th_percentile":2426.68},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":7564.0,"10th_percentile":7348.47,"90th_percentile":8431.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1707.1,"10th_percentile":1707.1,"90th_percentile":1707.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":7006.31,"10th_percentile":6999.82,"90th_percentile":7104.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7357.75,"10th_percentile":5663.57,"90th_percentile":7389.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"21","median_amount":2230.13,"10th_percentile":1486.1,"90th_percentile":2610.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"18","median_amount":5178.3,"10th_percentile":4092.38,"90th_percentile":10759.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1707.1,"10th_percentile":1707.1,"90th_percentile":2560.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3550.63,"10th_percentile":3550.63,"90th_percentile":3550.63},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":8844.87,"10th_percentile":8844.87,"90th_percentile":8844.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nerve Injections","code_information":[{"code":"5441","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":577.76,"10th_percentile":547.4,"90th_percentile":593.89},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2047.0,"10th_percentile":1908.54,"90th_percentile":2656.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2263.0,"10th_percentile":2263.0,"90th_percentile":2405.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":2021.08,"10th_percentile":2021.08,"90th_percentile":2021.08},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":561.12,"10th_percentile":561.12,"90th_percentile":561.12},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":602.12,"10th_percentile":491.63,"90th_percentile":1126.39},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":548.39,"10th_percentile":548.39,"90th_percentile":552.8},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":527.82,"10th_percentile":527.82,"90th_percentile":527.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"19","median_amount":570.47,"10th_percentile":489.05,"90th_percentile":1003.18},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1346.03,"10th_percentile":1346.03,"90th_percentile":1441.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":615.55,"10th_percentile":545.39,"90th_percentile":1052.82},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":1642.56,"10th_percentile":1562.3,"90th_percentile":3145.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":671.47,"10th_percentile":671.47,"90th_percentile":671.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":290.91,"10th_percentile":290.91,"90th_percentile":482.5},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":2373.25,"10th_percentile":2373.25,"90th_percentile":2373.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Nerve Injections","code_information":[{"code":"5442","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":883.43,"10th_percentile":883.43,"90th_percentile":883.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":894.78,"10th_percentile":894.78,"90th_percentile":894.78},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3504.0,"10th_percentile":3504.0,"90th_percentile":3504.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2654.0,"10th_percentile":2654.0,"90th_percentile":2654.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":956.69,"10th_percentile":883.43,"90th_percentile":956.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1075.59,"10th_percentile":1075.59,"90th_percentile":1075.59},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"21","median_amount":874.07,"10th_percentile":787.35,"90th_percentile":952.45},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":431.02,"10th_percentile":431.02,"90th_percentile":431.02},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":956.69,"10th_percentile":956.69,"90th_percentile":956.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":223.01,"10th_percentile":223.01,"90th_percentile":223.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":881.06,"10th_percentile":780.87,"90th_percentile":6734.41},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3375.77,"10th_percentile":3375.77,"90th_percentile":3375.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":838.07,"10th_percentile":639.08,"90th_percentile":989.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":2371.62,"10th_percentile":1758.02,"90th_percentile":2497.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":883.43,"10th_percentile":883.43,"90th_percentile":956.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":744.71,"10th_percentile":744.71,"90th_percentile":744.71},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Nerve Injections","code_information":[{"code":"5443","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2870.07,"10th_percentile":2870.07,"90th_percentile":3975.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3553.26,"10th_percentile":3552.97,"90th_percentile":5406.93},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2252.03,"10th_percentile":2123.2,"90th_percentile":14254.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":7152.96,"10th_percentile":7152.96,"90th_percentile":7152.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":6223.29,"10th_percentile":1912.17,"90th_percentile":9179.8},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"22","median_amount":2993.16,"10th_percentile":1091.18,"90th_percentile":8232.68},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1567.96,"10th_percentile":997.53,"90th_percentile":5906.52},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2870.08,"10th_percentile":2870.08,"90th_percentile":2870.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":4802.4,"10th_percentile":4802.4,"90th_percentile":4802.4},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":334.5,"10th_percentile":334.5,"90th_percentile":334.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"20","median_amount":2805.3,"10th_percentile":126.07,"90th_percentile":4051.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3278.97,"10th_percentile":3278.97,"90th_percentile":3278.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4182.26,"10th_percentile":3441.26,"90th_percentile":5468.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":1599.96,"10th_percentile":1103.63,"90th_percentile":3783.74},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":4834.66,"10th_percentile":4834.66,"90th_percentile":11379.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2870.08,"10th_percentile":2870.08,"90th_percentile":4305.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2968.68,"10th_percentile":2968.68,"90th_percentile":2968.68},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Intraocular Procedures","code_information":[{"code":"5491","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1982.71,"10th_percentile":1982.71,"90th_percentile":1982.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"14","median_amount":2475.66,"10th_percentile":2409.01,"90th_percentile":2758.72},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":4946.5,"10th_percentile":4946.5,"90th_percentile":4981.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"11","median_amount":3232.49,"10th_percentile":2611.13,"90th_percentile":4599.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1152.14,"10th_percentile":1152.14,"90th_percentile":1152.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"16","median_amount":2275.62,"10th_percentile":2023.44,"90th_percentile":2583.02},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":2500.63,"10th_percentile":2186.0,"90th_percentile":2928.91},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4442.31,"10th_percentile":4442.31,"90th_percentile":4442.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"11","median_amount":2274.13,"10th_percentile":2218.09,"90th_percentile":2696.44},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":9922.65,"10th_percentile":9922.65,"90th_percentile":9922.65},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"64","median_amount":2358.95,"10th_percentile":2109.76,"90th_percentile":2844.42},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":6960.22,"10th_percentile":6587.74,"90th_percentile":8447.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7486.3,"10th_percentile":7486.3,"90th_percentile":7486.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"61","median_amount":2525.66,"10th_percentile":2215.62,"90th_percentile":2982.59},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"23","median_amount":5926.95,"10th_percentile":5280.67,"90th_percentile":7220.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2166.9,"10th_percentile":2166.9,"90th_percentile":2166.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1972.51,"10th_percentile":1972.51,"90th_percentile":1972.51},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Imaging without Contrast","code_information":[{"code":"5521","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"1 through 10","median_amount":13.96,"10th_percentile":13.96,"90th_percentile":475.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"85","median_amount":215.47,"10th_percentile":69.71,"90th_percentile":389.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"112","median_amount":118.37,"10th_percentile":69.71,"90th_percentile":366.63},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"168","median_amount":141.76,"10th_percentile":64.74,"90th_percentile":817.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"296","median_amount":99.32,"10th_percentile":57.32,"90th_percentile":380.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":86.25,"10th_percentile":86.25,"90th_percentile":86.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"44","median_amount":207.25,"10th_percentile":73.2,"90th_percentile":385.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":443.0,"10th_percentile":443.0,"90th_percentile":919.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":109.81,"10th_percentile":73.2,"90th_percentile":371.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"27","median_amount":444.12,"10th_percentile":344.39,"90th_percentile":1017.45},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"54","median_amount":232.87,"10th_percentile":64.93,"90th_percentile":520.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"48","median_amount":160.21,"10th_percentile":77.66,"90th_percentile":404.7},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"124","median_amount":200.98,"10th_percentile":109.25,"90th_percentile":370.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"14","median_amount":353.39,"10th_percentile":353.39,"90th_percentile":706.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":645.83,"10th_percentile":645.83,"90th_percentile":645.83},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":353.39,"10th_percentile":339.88,"90th_percentile":582.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"90","median_amount":118.75,"10th_percentile":107.06,"90th_percentile":316.96},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":126.4,"10th_percentile":69.71,"90th_percentile":353.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":93.1,"10th_percentile":93.1,"90th_percentile":93.1},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":220.89,"10th_percentile":190.05,"90th_percentile":1149.34},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"20","median_amount":619.88,"10th_percentile":413.25,"90th_percentile":969.18},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":403.75,"10th_percentile":403.75,"90th_percentile":403.75},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"56","median_amount":236.05,"10th_percentile":73.2,"90th_percentile":385.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"614","median_amount":117.17,"10th_percentile":107.56,"90th_percentile":302.47},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"102","median_amount":579.89,"10th_percentile":475.0,"90th_percentile":1138.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"40","median_amount":224.8,"10th_percentile":69.71,"90th_percentile":458.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"105","median_amount":399.08,"10th_percentile":367.43,"90th_percentile":930.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"44","median_amount":474.44,"10th_percentile":285.0,"90th_percentile":712.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"1 through 10","median_amount":1269.4,"10th_percentile":1269.4,"90th_percentile":1269.4},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"350","median_amount":118.75,"10th_percentile":89.25,"90th_percentile":256.5},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"576","median_amount":244.0,"10th_percentile":242.0,"90th_percentile":589.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"159","median_amount":197.38,"10th_percentile":69.71,"90th_percentile":398.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":128.25,"10th_percentile":128.25,"90th_percentile":128.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":128.25,"10th_percentile":128.25,"90th_percentile":205.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"32","median_amount":107.06,"10th_percentile":85.65,"90th_percentile":257.41},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"141","median_amount":678.21,"10th_percentile":427.5,"90th_percentile":855.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":381.69,"10th_percentile":381.69,"90th_percentile":381.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Imaging without Contrast","code_information":[{"code":"5522","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"1 through 10","median_amount":1372.5,"10th_percentile":1372.5,"90th_percentile":1372.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"70","median_amount":125.37,"10th_percentile":69.71,"90th_percentile":229.39,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"118","median_amount":184.28,"10th_percentile":50.47,"90th_percentile":573.88},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"166","median_amount":595.2,"10th_percentile":96.72,"90th_percentile":1436.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"293","median_amount":551.0,"10th_percentile":93.39,"90th_percentile":1102.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"48","median_amount":131.64,"10th_percentile":122.27,"90th_percentile":252.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":968.0,"10th_percentile":943.0,"90th_percentile":1894.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":131.64,"10th_percentile":131.64,"90th_percentile":131.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"26","median_amount":529.2,"10th_percentile":403.75,"90th_percentile":992.8},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"84","median_amount":133.48,"10th_percentile":116.45,"90th_percentile":343.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"77","median_amount":167.7,"10th_percentile":51.86,"90th_percentile":499.78},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"97","median_amount":575.0,"10th_percentile":109.25,"90th_percentile":735.02},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"27","median_amount":468.0,"10th_percentile":374.4,"90th_percentile":1826.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":532.36,"10th_percentile":468.0,"90th_percentile":835.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"111","median_amount":170.7,"10th_percentile":50.47,"90th_percentile":618.5},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":133.48,"10th_percentile":116.45,"90th_percentile":215.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":509.77,"10th_percentile":167.92,"90th_percentile":715.41},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":347.85,"10th_percentile":347.85,"90th_percentile":411.44},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"27","median_amount":582.55,"10th_percentile":179.22,"90th_percentile":1066.62},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"59","median_amount":143.56,"10th_percentile":131.64,"90th_percentile":260.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"743","median_amount":183.08,"10th_percentile":77.17,"90th_percentile":643.21},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"99","median_amount":597.29,"10th_percentile":451.85,"90th_percentile":1476.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"30","median_amount":125.37,"10th_percentile":69.71,"90th_percentile":343.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"126","median_amount":665.15,"10th_percentile":339.08,"90th_percentile":2454.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"59","median_amount":558.0,"10th_percentile":154.5,"90th_percentile":1190.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"463","median_amount":199.26,"10th_percentile":60.49,"90th_percentile":620.77},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"586","median_amount":430.0,"10th_percentile":225.0,"90th_percentile":867.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":973.35,"10th_percentile":973.35,"90th_percentile":973.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"94","median_amount":136.72,"10th_percentile":69.71,"90th_percentile":351.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":95.75,"10th_percentile":95.75,"90th_percentile":95.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":196.83,"10th_percentile":196.83,"90th_percentile":200.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"22","median_amount":151.25,"10th_percentile":52.35,"90th_percentile":637.21},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"55","median_amount":801.9,"10th_percentile":427.5,"90th_percentile":2773.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Imaging without Contrast","code_information":[{"code":"5523","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":300.52,"10th_percentile":300.52,"90th_percentile":1177.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"25","median_amount":769.1,"10th_percentile":430.89,"90th_percentile":948.86},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"43","median_amount":3420.0,"10th_percentile":2112.8,"90th_percentile":3480.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"82","median_amount":2641.0,"10th_percentile":1097.57,"90th_percentile":2868.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2641.0,"10th_percentile":2641.0,"90th_percentile":2641.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":315.55,"10th_percentile":292.99,"90th_percentile":315.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":5796.0,"10th_percentile":5796.0,"90th_percentile":5796.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":2582.64,"10th_percentile":2220.56,"90th_percentile":2907.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"17","median_amount":300.52,"10th_percentile":279.04,"90th_percentile":370.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"28","median_amount":695.63,"10th_percentile":394.68,"90th_percentile":875.42},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"184","median_amount":800.4,"10th_percentile":746.12,"90th_percentile":1096.47},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2130.0,"10th_percentile":2130.0,"90th_percentile":2603.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2130.0,"10th_percentile":2130.0,"90th_percentile":2821.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"32","median_amount":494.9,"10th_percentile":342.22,"90th_percentile":786.6},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":300.52,"10th_percentile":300.52,"90th_percentile":558.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1133.13,"10th_percentile":1133.13,"90th_percentile":1133.13},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":930.67,"10th_percentile":552.5,"90th_percentile":1561.14},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2323.16,"10th_percentile":2082.78,"90th_percentile":3027.6},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":315.55,"10th_percentile":292.99,"90th_percentile":1379.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"202","median_amount":699.24,"10th_percentile":395.08,"90th_percentile":854.6},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"30","median_amount":2575.0,"10th_percentile":2089.97,"90th_percentile":2652.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":300.52,"10th_percentile":279.04,"90th_percentile":434.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"38","median_amount":3718.36,"10th_percentile":1595.61,"90th_percentile":4067.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"23","median_amount":2349.0,"10th_percentile":982.5,"90th_percentile":2784.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"157","median_amount":704.72,"10th_percentile":402.73,"90th_percentile":1002.11},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"153","median_amount":2528.0,"10th_percentile":1250.49,"90th_percentile":3328.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"23","median_amount":300.52,"10th_percentile":279.04,"90th_percentile":601.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":922.05,"10th_percentile":922.05,"90th_percentile":1432.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"14","median_amount":548.17,"10th_percentile":343.2,"90th_percentile":650.53},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"35","median_amount":3132.0,"10th_percentile":2919.6,"90th_percentile":3455.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Imaging without Contrast","code_information":[{"code":"5524","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":588.59,"10th_percentile":588.59,"90th_percentile":588.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"23","median_amount":761.09,"10th_percentile":661.99,"90th_percentile":957.33},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2434.78,"10th_percentile":1596.94,"90th_percentile":2934.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"20","median_amount":1787.56,"10th_percentile":1317.29,"90th_percentile":2715.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":600.84,"10th_percentile":600.84,"90th_percentile":600.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":2619.7,"10th_percentile":2619.7,"90th_percentile":2619.7},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":588.59,"10th_percentile":588.59,"90th_percentile":588.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"12","median_amount":695.18,"10th_percentile":694.88,"90th_percentile":785.29},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":1454.98,"10th_percentile":770.5,"90th_percentile":1644.16},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4327.51,"10th_percentile":4327.51,"90th_percentile":4327.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"18","median_amount":700.46,"10th_percentile":547.68,"90th_percentile":795.33},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":618.02,"10th_percentile":618.02,"90th_percentile":618.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"129","median_amount":755.89,"10th_percentile":695.48,"90th_percentile":896.29},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":2175.89,"10th_percentile":2076.6,"90th_percentile":2197.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":588.59,"10th_percentile":588.59,"90th_percentile":588.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2188.22,"10th_percentile":1592.05,"90th_percentile":2188.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":1849.2,"10th_percentile":1849.2,"90th_percentile":1849.2},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2493.98,"10th_percentile":2493.98,"90th_percentile":2493.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"77","median_amount":708.86,"10th_percentile":588.59,"90th_percentile":1208.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"39","median_amount":2141.99,"10th_percentile":1429.0,"90th_percentile":3949.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":588.59,"10th_percentile":588.59,"90th_percentile":588.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":832.14,"10th_percentile":832.14,"90th_percentile":832.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":694.68,"10th_percentile":604.07,"90th_percentile":783.18},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Imaging with Contrast","code_information":[{"code":"5571","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":402.12,"10th_percentile":402.12,"90th_percentile":1783.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"25","median_amount":815.74,"10th_percentile":507.67,"90th_percentile":1579.03},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2490.88,"10th_percentile":1588.85,"90th_percentile":5706.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"37","median_amount":1590.32,"10th_percentile":402.12,"90th_percentile":3172.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":22.38,"10th_percentile":22.38,"90th_percentile":22.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4654.27,"10th_percentile":3545.35,"90th_percentile":5138.45},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":402.12,"10th_percentile":351.57,"90th_percentile":804.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":788.0,"10th_percentile":722.75,"90th_percentile":1555.23},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"75","median_amount":799.95,"10th_percentile":355.88,"90th_percentile":1647.69},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2094.39,"10th_percentile":2094.39,"90th_percentile":2213.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":839.18,"10th_percentile":123.26,"90th_percentile":1796.83},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":10447.25,"10th_percentile":10447.25,"90th_percentile":10447.25},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":2022.47,"10th_percentile":2022.47,"90th_percentile":5693.93},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":422.23,"10th_percentile":422.23,"90th_percentile":1040.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"125","median_amount":812.23,"10th_percentile":337.74,"90th_percentile":1645.57},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"13","median_amount":2344.83,"10th_percentile":570.56,"90th_percentile":2457.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2906.6,"10th_percentile":1990.62,"90th_percentile":7056.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":4618.14,"10th_percentile":2119.83,"90th_percentile":4651.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"99","median_amount":858.84,"10th_percentile":344.59,"90th_percentile":1783.43},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"72","median_amount":1813.17,"10th_percentile":422.23,"90th_percentile":3613.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":495.5,"10th_percentile":264.98,"90th_percentile":859.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1783.36,"10th_percentile":1767.7,"90th_percentile":1783.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":711.56,"10th_percentile":249.16,"90th_percentile":1315.49},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":7715.94,"10th_percentile":7715.94,"90th_percentile":7715.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Imaging with Contrast","code_information":[{"code":"5572","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"1 through 10","median_amount":1094.05,"10th_percentile":1094.05,"90th_percentile":1094.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":505.46,"10th_percentile":402.12,"90th_percentile":627.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"36","median_amount":901.54,"10th_percentile":723.44,"90th_percentile":1223.1},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"34","median_amount":3565.28,"10th_percentile":1688.85,"90th_percentile":6166.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"62","median_amount":1692.48,"10th_percentile":1341.7,"90th_percentile":3045.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1534.04,"10th_percentile":530.73,"90th_percentile":1592.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3101.57,"10th_percentile":3101.57,"90th_percentile":3101.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":3172.34,"10th_percentile":3172.34,"90th_percentile":3398.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":714.84,"10th_percentile":714.84,"90th_percentile":714.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":4071.08,"10th_percentile":2647.75,"90th_percentile":5578.56},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":470.74,"10th_percentile":402.12,"90th_percentile":991.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":829.8,"10th_percentile":644.87,"90th_percentile":1014.72},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"143","median_amount":959.34,"10th_percentile":836.35,"90th_percentile":1851.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":2153.8,"10th_percentile":2094.58,"90th_percentile":2681.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":2898.47,"10th_percentile":2898.47,"90th_percentile":2898.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"29","median_amount":740.5,"10th_percentile":50.0,"90th_percentile":1700.29},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":505.46,"10th_percentile":402.12,"90th_percentile":1046.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":645.84,"10th_percentile":645.84,"90th_percentile":645.84},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":1224.73,"10th_percentile":1224.73,"90th_percentile":1224.73},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":4708.66,"10th_percentile":3505.45,"90th_percentile":5496.88},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":550.0,"10th_percentile":550.0,"90th_percentile":550.0},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":530.73,"10th_percentile":422.23,"90th_percentile":1381.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"133","median_amount":877.73,"10th_percentile":601.75,"90th_percentile":1462.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"15","median_amount":2390.04,"10th_percentile":2089.24,"90th_percentile":3012.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":402.12,"10th_percentile":402.12,"90th_percentile":1516.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"19","median_amount":3852.3,"10th_percentile":2940.7,"90th_percentile":7799.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2696.51,"10th_percentile":2397.75,"90th_percentile":6237.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"108","median_amount":863.08,"10th_percentile":639.28,"90th_percentile":1449.92},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"112","median_amount":1993.6,"10th_percentile":1514.09,"90th_percentile":4052.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":743.88,"10th_percentile":351.57,"90th_percentile":1402.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":842.81,"10th_percentile":842.81,"90th_percentile":864.25},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":4643.14,"10th_percentile":4643.14,"90th_percentile":4643.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Imaging with Contrast","code_information":[{"code":"5573","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1195.44,"10th_percentile":1195.44,"90th_percentile":1195.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1206.43,"10th_percentile":1056.01,"90th_percentile":1678.63},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"12","median_amount":3715.18,"10th_percentile":2744.71,"90th_percentile":4909.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2494.58,"10th_percentile":1947.35,"90th_percentile":4903.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":618.02,"10th_percentile":618.02,"90th_percentile":842.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. 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Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":802.85,"10th_percentile":802.85,"90th_percentile":802.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":3351.55,"10th_percentile":2681.24,"90th_percentile":3351.55},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1083.35,"10th_percentile":1083.35,"90th_percentile":1195.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1107.28,"10th_percentile":1060.0,"90th_percentile":1224.2},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":1129.88,"10th_percentile":1075.26,"90th_percentile":1532.56},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4132.98,"10th_percentile":4132.98,"90th_percentile":4132.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":3654.77,"10th_percentile":3654.77,"90th_percentile":3654.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":972.79,"10th_percentile":960.28,"90th_percentile":1110.28},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":500.81,"10th_percentile":500.81,"90th_percentile":500.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":885.82,"10th_percentile":885.82,"90th_percentile":885.82},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":4273.88,"10th_percentile":4273.88,"90th_percentile":4273.88},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"66","median_amount":1108.08,"10th_percentile":965.55,"90th_percentile":1372.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3036.51,"10th_percentile":2334.0,"90th_percentile":3468.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3338.95,"10th_percentile":2731.26,"90th_percentile":5091.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":3209.3,"10th_percentile":3209.3,"90th_percentile":5560.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"50","median_amount":1075.26,"10th_percentile":791.39,"90th_percentile":1311.56},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"25","median_amount":2974.84,"10th_percentile":1654.16,"90th_percentile":3839.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":795.7,"10th_percentile":795.7,"90th_percentile":795.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":885.44,"10th_percentile":885.44,"90th_percentile":885.44},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":4392.69,"10th_percentile":4392.69,"90th_percentile":5122.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Nuclear Medicine and Related Services","code_information":[{"code":"5591","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":882.91,"10th_percentile":882.91,"90th_percentile":882.91},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":177.01,"10th_percentile":177.01,"90th_percentile":177.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2608.6,"10th_percentile":905.42,"90th_percentile":4225.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":462.83,"10th_percentile":462.83,"90th_percentile":462.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":867.16,"10th_percentile":849.62,"90th_percentile":1694.25},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":849.05,"10th_percentile":849.05,"90th_percentile":849.05},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":485.97,"10th_percentile":485.97,"90th_percentile":485.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":846.44,"10th_percentile":814.9,"90th_percentile":1843.26},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":3567.83,"10th_percentile":3567.83,"90th_percentile":3567.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":4065.06,"10th_percentile":4065.06,"90th_percentile":4065.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2685.73,"10th_percentile":2685.73,"90th_percentile":2685.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1300.35,"10th_percentile":1300.35,"90th_percentile":2367.46},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":3131.47,"10th_percentile":2712.21,"90th_percentile":3744.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":715.59,"10th_percentile":715.59,"90th_percentile":715.59},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":3525.4,"10th_percentile":3525.4,"90th_percentile":3525.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 2 Nuclear Medicine and Related Services","code_information":[{"code":"5592","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2039.75,"10th_percentile":2039.75,"90th_percentile":2039.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":1688.49,"10th_percentile":1688.49,"90th_percentile":1688.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":596.67,"10th_percentile":596.67,"90th_percentile":596.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":623.74,"10th_percentile":623.74,"90th_percentile":623.74},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":1029.81,"10th_percentile":1029.81,"90th_percentile":1029.81},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":705.66,"10th_percentile":697.32,"90th_percentile":907.69},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":3118.04,"10th_percentile":3118.04,"90th_percentile":3118.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1880.75,"10th_percentile":1880.75,"90th_percentile":1880.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":2869.21,"10th_percentile":2666.9,"90th_percentile":3504.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":3604.96,"10th_percentile":3604.96,"90th_percentile":3604.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":3780.99,"10th_percentile":3780.99,"90th_percentile":3780.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Nuclear Medicine and Related Services","code_information":[{"code":"5593","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1354.97,"10th_percentile":1209.49,"90th_percentile":1354.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"22","median_amount":1802.72,"10th_percentile":1008.16,"90th_percentile":1809.84},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3615.19,"10th_percentile":2978.77,"90th_percentile":3837.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"15","median_amount":2941.4,"10th_percentile":2363.26,"90th_percentile":3115.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":5244.08,"10th_percentile":5244.08,"90th_percentile":5244.08},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1209.49,"10th_percentile":1209.49,"90th_percentile":1354.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1663.36,"10th_percentile":1650.84,"90th_percentile":1665.16},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"33","median_amount":1692.35,"10th_percentile":1692.35,"90th_percentile":2834.36},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5474.16,"10th_percentile":5474.16,"90th_percentile":5474.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"14","median_amount":1664.4,"10th_percentile":1326.8,"90th_percentile":2861.47},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1354.97,"10th_percentile":1354.97,"90th_percentile":1357.17,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":1038.28,"10th_percentile":1038.28,"90th_percentile":1038.28},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":494.21,"10th_percentile":494.21,"90th_percentile":494.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"104","median_amount":1666.37,"10th_percentile":1398.66,"90th_percentile":1810.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":5927.09,"10th_percentile":4059.48,"90th_percentile":11031.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1209.49,"10th_percentile":1209.49,"90th_percentile":1209.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":5992.54,"10th_percentile":5992.54,"90th_percentile":5992.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":7737.38,"10th_percentile":7737.38,"90th_percentile":7758.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"63","median_amount":1692.35,"10th_percentile":1483.54,"90th_percentile":2401.21},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"30","median_amount":4831.26,"10th_percentile":3600.1,"90th_percentile":5149.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1354.97,"10th_percentile":1354.97,"90th_percentile":1354.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1986.67,"10th_percentile":1986.67,"90th_percentile":1986.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2054.27,"10th_percentile":1585.04,"90th_percentile":2131.6},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Pathology","code_information":[{"code":"5672","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2760.0,"10th_percentile":2760.0,"90th_percentile":2760.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Drug Administration","code_information":[{"code":"5691","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3197.72,"10th_percentile":2862.76,"90th_percentile":3638.89},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":12240.75,"10th_percentile":9373.0,"90th_percentile":13941.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9009.0,"10th_percentile":8316.0,"90th_percentile":9702.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2789.8,"10th_percentile":2575.2,"90th_percentile":3004.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":2665.54,"10th_percentile":2665.54,"90th_percentile":2665.54},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4293.32,"10th_percentile":4293.32,"90th_percentile":4293.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":5131.93,"10th_percentile":5131.93,"90th_percentile":5131.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"12","median_amount":4760.0,"10th_percentile":3770.81,"90th_percentile":7107.12},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":4262.48,"10th_percentile":4262.48,"90th_percentile":4262.48},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2789.8,"10th_percentile":2789.8,"90th_percentile":2789.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"42","median_amount":3749.65,"10th_percentile":3114.48,"90th_percentile":4544.61},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2789.8,"10th_percentile":2789.8,"90th_percentile":2948.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":11918.76,"10th_percentile":11279.41,"90th_percentile":22231.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"36","median_amount":2990.0,"10th_percentile":1656.0,"90th_percentile":3220.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":7099.0,"10th_percentile":6420.0,"90th_percentile":8560.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2000.0,"10th_percentile":2000.0,"90th_percentile":2350.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"14","median_amount":3589.74,"10th_percentile":2960.24,"90th_percentile":4445.58},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Drug Administration","code_information":[{"code":"5692","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":246.69,"10th_percentile":168.78,"90th_percentile":5456.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"19","median_amount":170.91,"10th_percentile":120.06,"90th_percentile":366.65},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"15","median_amount":347.41,"10th_percentile":247.59,"90th_percentile":870.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"23","median_amount":185.0,"10th_percentile":135.44,"90th_percentile":1450.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":211.42,"10th_percentile":187.83,"90th_percentile":417.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":605.06,"10th_percentile":605.06,"90th_percentile":605.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":243.97,"10th_percentile":243.97,"90th_percentile":470.02},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":168.78,"10th_percentile":148.71,"90th_percentile":401.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1078.72,"10th_percentile":1042.22,"90th_percentile":1078.73},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":98.68,"10th_percentile":96.26,"90th_percentile":19860.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"11","median_amount":441.55,"10th_percentile":387.38,"90th_percentile":813.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":330.44,"10th_percentile":330.44,"90th_percentile":340.0},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":734.88,"10th_percentile":299.22,"90th_percentile":1782.97},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":215.47,"10th_percentile":215.47,"90th_percentile":215.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":123.33,"10th_percentile":123.33,"90th_percentile":123.33},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":341.81,"10th_percentile":205.29,"90th_percentile":366.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"84","median_amount":622.68,"10th_percentile":169.11,"90th_percentile":1583.66},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":344.59,"10th_percentile":277.0,"90th_percentile":658.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":162.34,"10th_percentile":148.71,"90th_percentile":391.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"18","median_amount":352.34,"10th_percentile":178.77,"90th_percentile":1956.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":278.15,"10th_percentile":67.02,"90th_percentile":3065.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"47","median_amount":149.67,"10th_percentile":70.44,"90th_percentile":645.32},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"55","median_amount":117.99,"10th_percentile":1.41,"90th_percentile":909.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"17","median_amount":201.35,"10th_percentile":168.78,"90th_percentile":329.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"11","median_amount":76.5,"10th_percentile":20.58,"90th_percentile":1364.5},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"22","median_amount":421.75,"10th_percentile":362.25,"90th_percentile":722.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":339.67,"10th_percentile":339.67,"90th_percentile":339.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 3 Drug Administration","code_information":[{"code":"5693","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":846.27,"10th_percentile":312.07,"90th_percentile":2026.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"23","median_amount":842.25,"10th_percentile":456.57,"90th_percentile":2050.04},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"16","median_amount":9066.46,"10th_percentile":1186.21,"90th_percentile":13110.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"15","median_amount":2011.65,"10th_percentile":574.65,"90th_percentile":4167.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":1380.38,"10th_percentile":513.92,"90th_percentile":2091.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1521.53,"10th_percentile":1521.53,"90th_percentile":1521.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":210.75,"10th_percentile":180.61,"90th_percentile":396.9},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"60","median_amount":4333.67,"10th_percentile":1023.82,"90th_percentile":5073.51},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"12","median_amount":6108.41,"10th_percentile":1823.08,"90th_percentile":8249.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"12","median_amount":764.95,"10th_percentile":459.9,"90th_percentile":1608.65},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":53.55,"10th_percentile":53.55,"90th_percentile":53.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":545.03,"10th_percentile":545.03,"90th_percentile":545.03},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1103.56,"10th_percentile":1060.88,"90th_percentile":1171.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"88","median_amount":1096.4,"10th_percentile":232.03,"90th_percentile":3447.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"20","median_amount":14351.56,"10th_percentile":1207.61,"90th_percentile":14376.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":899.46,"10th_percentile":312.94,"90th_percentile":5425.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":3165.01,"10th_percentile":1336.75,"90th_percentile":3848.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":2648.88,"10th_percentile":1428.18,"90th_percentile":7732.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"69","median_amount":704.21,"10th_percentile":144.32,"90th_percentile":3316.23},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"33","median_amount":1769.62,"10th_percentile":422.59,"90th_percentile":11014.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":1168.78,"10th_percentile":1168.78,"90th_percentile":1168.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":693.5,"10th_percentile":564.97,"90th_percentile":1555.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"16","median_amount":454.6,"10th_percentile":389.4,"90th_percentile":1478.92},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":4098.99,"10th_percentile":893.7,"90th_percentile":25733.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":2200.46,"10th_percentile":2200.46,"90th_percentile":2200.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Level 4 Drug Administration","code_information":[{"code":"5694","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":2507.79,"10th_percentile":2507.79,"90th_percentile":2507.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":2464.89,"10th_percentile":2345.01,"90th_percentile":4136.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"48","median_amount":2734.42,"10th_percentile":2204.1,"90th_percentile":4547.34},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1555.25,"10th_percentile":1555.25,"90th_percentile":1555.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1633.01,"10th_percentile":1633.01,"90th_percentile":1633.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"22","median_amount":2096.25,"10th_percentile":1459.97,"90th_percentile":2277.28},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":520.44,"10th_percentile":230.52,"90th_percentile":1225.57},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":3459.33,"10th_percentile":2491.88,"90th_percentile":30689.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Diagnostic Tests and Related Services","code_information":[{"code":"5721","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":72.74,"10th_percentile":72.74,"90th_percentile":72.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":106.33,"10th_percentile":106.33,"90th_percentile":106.33},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":342.86,"10th_percentile":342.86,"90th_percentile":342.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":110.58,"10th_percentile":110.58,"90th_percentile":110.58},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":62.79,"10th_percentile":62.79,"90th_percentile":62.79},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":97.82,"10th_percentile":97.82,"90th_percentile":97.82},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":106.73,"10th_percentile":106.73,"90th_percentile":118.22},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":325.5,"10th_percentile":325.5,"90th_percentile":325.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":99.82,"10th_percentile":99.82,"90th_percentile":127.24},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":301.63,"10th_percentile":301.63,"90th_percentile":658.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Diagnostic Tests and Related Services","code_information":[{"code":"5722","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":258.75,"10th_percentile":258.75,"90th_percentile":271.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":514.39,"10th_percentile":428.25,"90th_percentile":733.2},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":1380.92,"10th_percentile":1217.42,"90th_percentile":1658.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"14","median_amount":1013.84,"10th_percentile":928.0,"90th_percentile":1264.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":285.45,"10th_percentile":285.45,"90th_percentile":285.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":599.0,"10th_percentile":599.0,"90th_percentile":599.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":549.31,"10th_percentile":549.31,"90th_percentile":549.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":471.04,"10th_percentile":361.14,"90th_percentile":1108.87},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"37","median_amount":400.0,"10th_percentile":110.63,"90th_percentile":500.75},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":1561.61,"10th_percentile":1561.61,"90th_percentile":1561.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"11","median_amount":465.94,"10th_percentile":394.9,"90th_percentile":577.46},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":315.2,"10th_percentile":315.2,"90th_percentile":3768.74},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1520.76,"10th_percentile":1520.76,"90th_percentile":1520.76},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":651.73,"10th_percentile":651.73,"90th_percentile":651.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"48","median_amount":473.51,"10th_percentile":394.39,"90th_percentile":628.94},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1129.6,"10th_percentile":1129.6,"90th_percentile":1129.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1444.5,"10th_percentile":1444.5,"90th_percentile":1444.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1311.0,"10th_percentile":1200.0,"90th_percentile":1899.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"47","median_amount":471.96,"10th_percentile":368.0,"90th_percentile":671.22},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"24","median_amount":1214.87,"10th_percentile":686.46,"90th_percentile":1458.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":241.85,"10th_percentile":191.64,"90th_percentile":405.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":384.93,"10th_percentile":384.93,"90th_percentile":384.93},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1889.1,"10th_percentile":1889.1,"90th_percentile":1889.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Minor Procedures","code_information":[{"code":"5732","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":51.25,"10th_percentile":50.43,"90th_percentile":484.08},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":129.56,"10th_percentile":118.9,"90th_percentile":161.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":118.9,"10th_percentile":118.9,"90th_percentile":161.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":73.59,"10th_percentile":73.59,"90th_percentile":73.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"12","median_amount":47.15,"10th_percentile":47.15,"90th_percentile":53.3},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":51.25,"10th_percentile":51.25,"90th_percentile":51.25},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":46.4,"10th_percentile":46.4,"90th_percentile":46.4},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":77.27,"10th_percentile":77.27,"90th_percentile":77.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"21","median_amount":51.02,"10th_percentile":47.01,"90th_percentile":445.36},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":144.73,"10th_percentile":144.73,"90th_percentile":144.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":145.55,"10th_percentile":145.55,"90th_percentile":145.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"15","median_amount":51.25,"10th_percentile":5.35,"90th_percentile":181.8},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"11","median_amount":142.48,"10th_percentile":142.48,"90th_percentile":142.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":73.59,"10th_percentile":73.59,"90th_percentile":73.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":47.15,"10th_percentile":47.15,"90th_percentile":47.15},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Minor Procedures","code_information":[{"code":"5733","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":73.59,"10th_percentile":73.59,"90th_percentile":333.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"14","median_amount":174.19,"10th_percentile":37.24,"90th_percentile":472.3},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"12","median_amount":1202.58,"10th_percentile":158.92,"90th_percentile":1516.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"27","median_amount":139.2,"10th_percentile":69.6,"90th_percentile":1113.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":260.93,"10th_percentile":203.83,"90th_percentile":395.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":1632.0,"10th_percentile":1632.0,"90th_percentile":1632.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":73.59,"10th_percentile":71.42,"90th_percentile":316.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":432.77,"10th_percentile":432.77,"90th_percentile":432.77},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"33","median_amount":441.6,"10th_percentile":227.7,"90th_percentile":499.2},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":346.21,"10th_percentile":170.76,"90th_percentile":441.6},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":194.12,"10th_percentile":194.12,"90th_percentile":194.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":376.32,"10th_percentile":376.32,"90th_percentile":376.32},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":2526.88,"10th_percentile":2526.88,"90th_percentile":2526.88},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":128.7,"10th_percentile":128.7,"90th_percentile":128.7},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":560.57,"10th_percentile":560.57,"90th_percentile":560.57},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"72","median_amount":231.94,"10th_percentile":45.4,"90th_percentile":471.0},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1355.52,"10th_percentile":396.06,"90th_percentile":1355.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":71.42,"10th_percentile":71.42,"90th_percentile":71.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":1363.2,"10th_percentile":317.65,"90th_percentile":2008.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"1 through 10","median_amount":2808.3,"10th_percentile":2808.3,"90th_percentile":2808.3},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1296.0,"10th_percentile":1296.0,"90th_percentile":1596.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"59","median_amount":378.35,"10th_percentile":40.32,"90th_percentile":491.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"39","median_amount":499.47,"10th_percentile":105.3,"90th_percentile":1334.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":180.14,"10th_percentile":53.55,"90th_percentile":333.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":397.76,"10th_percentile":397.76,"90th_percentile":397.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 4 Minor Procedures","code_information":[{"code":"5734","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":89.53,"10th_percentile":86.89,"90th_percentile":353.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"17","median_amount":209.23,"10th_percentile":86.24,"90th_percentile":629.44},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"12","median_amount":601.98,"10th_percentile":583.02,"90th_percentile":1023.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"16","median_amount":196.0,"10th_percentile":184.99,"90th_percentile":480.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":371.64,"10th_percentile":371.64,"90th_percentile":371.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":627.3,"10th_percentile":627.3,"90th_percentile":627.3},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":73.59,"10th_percentile":73.59,"90th_percentile":73.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":186.86,"10th_percentile":79.34,"90th_percentile":320.09},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"36","median_amount":191.88,"10th_percentile":169.74,"90th_percentile":327.0},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":987.8,"10th_percentile":987.8,"90th_percentile":987.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":168.25,"10th_percentile":144.13,"90th_percentile":237.06},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":144.65,"10th_percentile":144.65,"90th_percentile":144.65},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":1374.75,"10th_percentile":1374.75,"90th_percentile":1374.75},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":275.62,"10th_percentile":275.62,"90th_percentile":275.62},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":132.72,"10th_percentile":132.72,"90th_percentile":132.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"60","median_amount":182.61,"10th_percentile":92.61,"90th_percentile":380.62},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":954.37,"10th_percentile":521.03,"90th_percentile":1063.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":523.98,"10th_percentile":523.98,"90th_percentile":846.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":553.5,"10th_percentile":498.15,"90th_percentile":981.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"52","median_amount":190.67,"10th_percentile":88.0,"90th_percentile":465.08},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"41","median_amount":512.91,"10th_percentile":207.74,"90th_percentile":759.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":323.75,"10th_percentile":73.59,"90th_percentile":353.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":173.61,"10th_percentile":173.61,"90th_percentile":173.61},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":994.5,"10th_percentile":735.3,"90th_percentile":2345.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 5 Minor Procedures","code_information":[{"code":"5735","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":192.38,"10th_percentile":192.38,"90th_percentile":192.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":917.05,"10th_percentile":917.05,"90th_percentile":917.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":1145.69,"10th_percentile":1145.69,"90th_percentile":1145.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Electronic Analysis of Devices","code_information":[{"code":"5741","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":50.96,"10th_percentile":50.96,"90th_percentile":50.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":138.61,"10th_percentile":138.61,"90th_percentile":138.61},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":440.82,"10th_percentile":440.82,"90th_percentile":440.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":323.64,"10th_percentile":323.64,"90th_percentile":323.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":48.23,"10th_percentile":48.23,"90th_percentile":48.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":128.34,"10th_percentile":128.34,"90th_percentile":139.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":128.34,"10th_percentile":128.34,"90th_percentile":128.34},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":100.62,"10th_percentile":100.62,"90th_percentile":100.62},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"12","median_amount":126.57,"10th_percentile":97.51,"90th_percentile":138.51},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":393.95,"10th_percentile":393.95,"90th_percentile":393.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":50.96,"10th_percentile":50.96,"90th_percentile":50.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":356.56,"10th_percentile":356.56,"90th_percentile":356.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":418.5,"10th_percentile":418.5,"90th_percentile":418.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":128.34,"10th_percentile":78.34,"90th_percentile":178.34},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"13","median_amount":387.81,"10th_percentile":290.86,"90th_percentile":391.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":50.96,"10th_percentile":50.96,"90th_percentile":50.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":100.62,"10th_percentile":100.62,"90th_percentile":100.62},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Rehabilitation","code_information":[{"code":"5771","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":319.88,"10th_percentile":99.96,"90th_percentile":1211.98},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":916.0,"10th_percentile":916.0,"90th_percentile":916.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"15","median_amount":1728.0,"10th_percentile":1080.0,"90th_percentile":2592.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":395.04,"10th_percentile":395.04,"90th_percentile":395.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":752.44,"10th_percentile":360.92,"90th_percentile":1316.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":703.15,"10th_percentile":602.7,"90th_percentile":904.05},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":509.45,"10th_percentile":212.16,"90th_percentile":954.72},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":659.16,"10th_percentile":659.16,"90th_percentile":1214.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":205.86,"10th_percentile":100.45,"90th_percentile":502.8},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":564.33,"10th_percentile":188.11,"90th_percentile":752.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":1517.7,"10th_percentile":1517.7,"90th_percentile":1517.7},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"52","median_amount":331.88,"10th_percentile":105.11,"90th_percentile":902.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":1251.04,"10th_percentile":590.22,"90th_percentile":3768.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":2845.77,"10th_percentile":943.59,"90th_percentile":4088.89,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":570.7,"10th_percentile":570.7,"90th_percentile":570.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"44","median_amount":509.45,"10th_percentile":119.61,"90th_percentile":991.44},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"30","median_amount":1847.34,"10th_percentile":615.77,"90th_percentile":2811.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":752.44,"10th_percentile":752.44,"90th_percentile":1504.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":118.04,"10th_percentile":87.0,"90th_percentile":319.52},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Resuscitation and Cardioversion","code_information":[{"code":"5781","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":4741.59,"10th_percentile":4741.59,"90th_percentile":4741.59,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Treatment","code_information":[{"code":"5791","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":305.97,"10th_percentile":232.87,"90th_percentile":626.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":134.56,"10th_percentile":134.56,"90th_percentile":292.1},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":412.19,"10th_percentile":208.57,"90th_percentile":1144.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":185.0,"10th_percentile":98.0,"90th_percentile":3928.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":66.67,"10th_percentile":66.67,"90th_percentile":66.67,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":244.51,"10th_percentile":244.51,"90th_percentile":276.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":244.87,"10th_percentile":240.06,"90th_percentile":547.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":127.89,"10th_percentile":127.89,"90th_percentile":127.89},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":322.06,"10th_percentile":322.06,"90th_percentile":418.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":432.6,"10th_percentile":432.6,"90th_percentile":432.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":626.1,"10th_percentile":626.1,"90th_percentile":626.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":715.6,"10th_percentile":447.68,"90th_percentile":1229.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":1138.03,"10th_percentile":1138.03,"90th_percentile":1138.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":253.17,"10th_percentile":253.17,"90th_percentile":253.17},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"19","median_amount":488.61,"10th_percentile":6.66,"90th_percentile":1402.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":244.87,"10th_percentile":206.61,"90th_percentile":458.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Health and Behavior Services","code_information":[{"code":"5822","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":382.0,"10th_percentile":191.0,"90th_percentile":764.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":382.0,"10th_percentile":382.0,"90th_percentile":382.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"1 through 10","median_amount":546.46,"10th_percentile":504.8,"90th_percentile":624.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":123.0,"10th_percentile":123.0,"90th_percentile":123.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 3 Health and Behavior Services","code_information":[{"code":"5823","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"30","median_amount":183.13,"10th_percentile":139.0,"90th_percentile":417.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"21","median_amount":58.8,"10th_percentile":36.25,"90th_percentile":85.81},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"80","median_amount":191.0,"10th_percentile":139.0,"90th_percentile":360.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"276","median_amount":211.5,"10th_percentile":139.0,"90th_percentile":451.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":294.0,"10th_percentile":294.0,"90th_percentile":294.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":183.13,"10th_percentile":183.13,"90th_percentile":183.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"49","median_amount":183.13,"10th_percentile":139.0,"90th_percentile":366.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":178.71,"10th_percentile":139.0,"90th_percentile":185.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"18","median_amount":422.45,"10th_percentile":183.13,"90th_percentile":651.95},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"44","median_amount":178.71,"10th_percentile":139.0,"90th_percentile":352.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"29","median_amount":67.62,"10th_percentile":31.33,"90th_percentile":141.42},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"28","median_amount":220.21,"10th_percentile":116.8,"90th_percentile":357.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"25","median_amount":177.34,"10th_percentile":119.68,"90th_percentile":215.76},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"49","median_amount":66.27,"10th_percentile":34.05,"90th_percentile":115.82},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":194.3,"10th_percentile":157.0,"90th_percentile":366.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":53.02,"10th_percentile":53.02,"90th_percentile":88.07},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":280.0,"10th_percentile":178.71,"90th_percentile":638.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":182.58,"10th_percentile":182.58,"90th_percentile":182.58},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":257.52,"10th_percentile":120.93,"90th_percentile":376.71},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":183.13,"10th_percentile":139.0,"90th_percentile":357.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"108","median_amount":62.66,"10th_percentile":34.05,"90th_percentile":90.64},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"21","median_amount":196.26,"10th_percentile":98.13,"90th_percentile":245.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"20","median_amount":183.13,"10th_percentile":155.8,"90th_percentile":536.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"48","median_amount":142.71,"10th_percentile":111.47,"90th_percentile":307.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"36","median_amount":208.5,"10th_percentile":104.25,"90th_percentile":429.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":82.89,"10th_percentile":70.16,"90th_percentile":143.25},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":143.25,"10th_percentile":82.75,"90th_percentile":333.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":138.75,"10th_percentile":75.67,"90th_percentile":540.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":140.75,"10th_percentile":114.6,"90th_percentile":227.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":73.5,"10th_percentile":73.5,"90th_percentile":73.5},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":127.6,"10th_percentile":127.6,"90th_percentile":137.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Alteplase recombinant","code_information":[{"code":"7048","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":9702.0,"10th_percentile":9702.0,"90th_percentile":9702.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2789.8,"10th_percentile":2789.8,"90th_percentile":2789.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1852.32,"10th_percentile":1852.32,"90th_percentile":3269.14},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3220.0,"10th_percentile":3220.0,"90th_percentile":3220.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj glucagon hcl, fresenius","code_information":[{"code":"9025","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":177.22,"10th_percentile":177.22,"90th_percentile":177.22},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj, etelcalcetide, 0.1 mg","code_information":[{"code":"9031","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1388.75,"10th_percentile":1388.75,"90th_percentile":1555.52},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":4348.5,"10th_percentile":4348.5,"90th_percentile":4387.11},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2300.0,"10th_percentile":1840.0,"90th_percentile":3004.4},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj retacrit esrd on dialysi","code_information":[{"code":"9096","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":9009.0,"10th_percentile":9009.0,"90th_percentile":9009.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2681.51,"10th_percentile":2681.51,"90th_percentile":2681.51},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Difelikefalin, esrd on dialy","code_information":[{"code":"9202","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2789.8,"10th_percentile":2575.2,"90th_percentile":3004.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Covid-19 Vaccine Administration","code_information":[{"code":"9398","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2836.92,"10th_percentile":2836.92,"90th_percentile":2836.92},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":6498.7,"10th_percentile":6498.7,"90th_percentile":6498.7,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2789.8,"10th_percentile":2789.8,"90th_percentile":2789.8,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"12","median_amount":3900.26,"10th_percentile":3497.64,"90th_percentile":4527.04},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":10721.19,"10th_percentile":10721.19,"90th_percentile":10721.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":2575.2,"10th_percentile":2444.66,"90th_percentile":3220.0},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":4314.56,"10th_percentile":4314.56,"90th_percentile":4314.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":3739.15,"10th_percentile":3739.15,"90th_percentile":3739.15},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Platelet pheres leukoreduced","code_information":[{"code":"9501","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":594.08,"10th_percentile":594.08,"90th_percentile":594.08},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-OPPS Clinic Services","code_information":[{"code":"N700","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"99","median_amount":167.86,"10th_percentile":123.0,"90th_percentile":265.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"53","median_amount":68.99,"10th_percentile":28.25,"90th_percentile":130.47},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"133","median_amount":197.5,"10th_percentile":113.0,"90th_percentile":226.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"210","median_amount":175.75,"10th_percentile":92.0,"90th_percentile":185.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"53","median_amount":192.05,"10th_percentile":144.38,"90th_percentile":262.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"17","median_amount":123.0,"10th_percentile":113.0,"90th_percentile":123.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":238.21,"10th_percentile":238.21,"90th_percentile":238.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":200.1,"10th_percentile":123.0,"90th_percentile":287.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"11","median_amount":122.44,"10th_percentile":71.7,"90th_percentile":274.55},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"68","median_amount":192.15,"10th_percentile":113.0,"90th_percentile":260.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"37","median_amount":61.08,"10th_percentile":27.72,"90th_percentile":64.69},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"42","median_amount":67.75,"10th_percentile":62.33,"90th_percentile":78.43},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"26","median_amount":91.5,"10th_percentile":91.5,"90th_percentile":228.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":202.62,"10th_percentile":202.62,"90th_percentile":202.62},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":196.41,"10th_percentile":88.01,"90th_percentile":213.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"69","median_amount":61.08,"10th_percentile":19.6,"90th_percentile":118.51},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"22","median_amount":214.44,"10th_percentile":123.0,"90th_percentile":248.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":22.18,"10th_percentile":22.18,"90th_percentile":64.94},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":22.97,"10th_percentile":22.18,"90th_percentile":48.86},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":249.69,"10th_percentile":65.74,"90th_percentile":250.06},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":123.0,"10th_percentile":123.0,"90th_percentile":123.0},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"59","median_amount":203.83,"10th_percentile":130.59,"90th_percentile":244.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"279","median_amount":64.68,"10th_percentile":27.68,"90th_percentile":134.55},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"73","median_amount":186.38,"10th_percentile":86.84,"90th_percentile":203.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"51","median_amount":188.0,"10th_percentile":123.0,"90th_percentile":250.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"123","median_amount":177.5,"10th_percentile":80.23,"90th_percentile":203.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"38","median_amount":151.76,"10th_percentile":84.75,"90th_percentile":215.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"1 through 10","median_amount":100.0,"10th_percentile":100.0,"90th_percentile":100.0},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"167","median_amount":66.01,"10th_percentile":43.24,"90th_percentile":80.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"337","median_amount":188.35,"10th_percentile":123.0,"90th_percentile":209.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":92.25,"10th_percentile":84.75,"90th_percentile":168.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"184","median_amount":214.8,"10th_percentile":137.5,"90th_percentile":266.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":87.25,"10th_percentile":87.25,"90th_percentile":87.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"22","median_amount":66.39,"10th_percentile":28.71,"90th_percentile":72.8},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"76","median_amount":258.3,"10th_percentile":225.0,"90th_percentile":267.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":195.66,"10th_percentile":195.66,"90th_percentile":195.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Clinical Diagnostic Lab Services","code_information":[{"code":"N800","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"37","median_amount":325.53,"10th_percentile":204.63,"90th_percentile":448.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"93","median_amount":112.68,"10th_percentile":60.02,"90th_percentile":263.12},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"72","median_amount":493.75,"10th_percentile":196.0,"90th_percentile":962.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"175","median_amount":185.0,"10th_percentile":57.33,"90th_percentile":239.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"35","median_amount":341.81,"10th_percentile":216.94,"90th_percentile":495.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":451.02,"10th_percentile":451.02,"90th_percentile":518.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":360.46,"10th_percentile":260.94,"90th_percentile":805.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"24","median_amount":145.35,"10th_percentile":48.45,"90th_percentile":765.13},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"36","median_amount":384.29,"10th_percentile":220.87,"90th_percentile":528.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":107.0,"10th_percentile":107.0,"90th_percentile":252.9},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":71.53,"10th_percentile":71.53,"90th_percentile":154.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"25","median_amount":182.28,"10th_percentile":42.41,"90th_percentile":729.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":570.78,"10th_percentile":457.23,"90th_percentile":4742.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"30","median_amount":169.05,"10th_percentile":91.35,"90th_percentile":3264.0},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":240.26,"10th_percentile":240.26,"90th_percentile":240.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":341.04,"10th_percentile":74.69,"90th_percentile":1079.67},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"31","median_amount":341.81,"10th_percentile":216.94,"90th_percentile":410.69,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"432","median_amount":110.98,"10th_percentile":55.49,"90th_percentile":263.74},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"39","median_amount":467.37,"10th_percentile":336.47,"90th_percentile":859.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"25","median_amount":278.55,"10th_percentile":206.61,"90th_percentile":391.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"70","median_amount":363.52,"10th_percentile":128.77,"90th_percentile":821.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"22","median_amount":257.82,"10th_percentile":185.92,"90th_percentile":550.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"218","median_amount":112.7,"10th_percentile":56.35,"90th_percentile":281.75},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"250","median_amount":23.16,"10th_percentile":4.29,"90th_percentile":448.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":119.82,"10th_percentile":17.14,"90th_percentile":190.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"125","median_amount":256.58,"10th_percentile":206.61,"90th_percentile":449.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":124.2,"10th_percentile":74.6,"90th_percentile":310.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"19","median_amount":165.69,"10th_percentile":60.02,"90th_percentile":271.39},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"1 through 10","median_amount":530.03,"10th_percentile":530.03,"90th_percentile":530.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":477.96,"10th_percentile":477.96,"90th_percentile":477.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Therapy Services","code_information":[{"code":"N801","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"1 through 10","median_amount":50.44,"10th_percentile":50.44,"90th_percentile":50.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"35","median_amount":176.48,"10th_percentile":62.66,"90th_percentile":533.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"81","median_amount":130.22,"10th_percentile":77.42,"90th_percentile":369.1},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"63","median_amount":389.0,"10th_percentile":205.6,"90th_percentile":2212.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"156","median_amount":596.0,"10th_percentile":219.3,"90th_percentile":1788.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":257.0,"10th_percentile":257.0,"90th_percentile":257.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"15","median_amount":115.24,"10th_percentile":84.13,"90th_percentile":263.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":227.0,"10th_percentile":227.0,"90th_percentile":227.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":376.46,"10th_percentile":376.46,"90th_percentile":376.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":354.45,"10th_percentile":305.65,"90th_percentile":1999.2},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":94.14,"10th_percentile":59.16,"90th_percentile":188.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"49","median_amount":178.54,"10th_percentile":48.26,"90th_percentile":540.36},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"16","median_amount":135.5,"10th_percentile":62.33,"90th_percentile":312.96},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":704.02,"10th_percentile":352.0,"90th_percentile":1819.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":1364.95,"10th_percentile":467.25,"90th_percentile":1546.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"65","median_amount":178.52,"10th_percentile":62.96,"90th_percentile":549.33},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":152.64,"10th_percentile":121.26,"90th_percentile":390.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":100.44,"10th_percentile":100.44,"90th_percentile":100.44},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":86.56,"10th_percentile":86.56,"90th_percentile":86.56},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"23","median_amount":481.98,"10th_percentile":179.22,"90th_percentile":1320.66},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":330.58,"10th_percentile":330.58,"90th_percentile":330.58},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"17","median_amount":125.1,"10th_percentile":65.79,"90th_percentile":646.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"412","median_amount":179.15,"10th_percentile":60.31,"90th_percentile":540.58},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"54","median_amount":605.61,"10th_percentile":326.61,"90th_percentile":1366.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":183.69,"10th_percentile":77.4,"90th_percentile":355.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"44","median_amount":1139.16,"10th_percentile":292.52,"90th_percentile":2568.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"47","median_amount":521.25,"10th_percentile":237.6,"90th_percentile":2079.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"201","median_amount":168.75,"10th_percentile":52.34,"90th_percentile":521.37},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"292","median_amount":568.0,"10th_percentile":227.2,"90th_percentile":1704.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"45","median_amount":158.78,"10th_percentile":79.08,"90th_percentile":406.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":154.25,"10th_percentile":142.14,"90th_percentile":211.94},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"117","median_amount":925.02,"10th_percentile":308.88,"90th_percentile":2062.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mammography Services","code_information":[{"code":"N804","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"11","median_amount":88.08,"10th_percentile":82.75,"90th_percentile":88.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"35","median_amount":105.34,"10th_percentile":105.34,"90th_percentile":105.34},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"91","median_amount":303.65,"10th_percentile":237.3,"90th_percentile":317.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"155","median_amount":225.3,"10th_percentile":225.3,"90th_percentile":237.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":92.49,"10th_percentile":92.49,"90th_percentile":92.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"1 through 10","median_amount":356.9,"10th_percentile":356.9,"90th_percentile":356.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":58.72,"10th_percentile":58.72,"90th_percentile":58.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"13","median_amount":365.5,"10th_percentile":365.5,"90th_percentile":365.5},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":88.08,"10th_percentile":82.75,"90th_percentile":88.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"24","median_amount":96.92,"10th_percentile":96.92,"90th_percentile":109.57},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":107.5,"10th_percentile":98.9,"90th_percentile":107.5},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":319.91,"10th_percentile":319.91,"90th_percentile":639.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":319.91,"10th_percentile":307.68,"90th_percentile":319.91,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"37","median_amount":96.92,"10th_percentile":96.92,"90th_percentile":105.35},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.08,"10th_percentile":88.08,"90th_percentile":88.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":77.54,"10th_percentile":77.54,"90th_percentile":105.78},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"13","median_amount":374.1,"10th_percentile":374.1,"90th_percentile":374.1},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":201.66,"10th_percentile":201.66,"90th_percentile":430.0},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":92.49,"10th_percentile":86.89,"90th_percentile":92.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"289","median_amount":105.34,"10th_percentile":96.92,"90th_percentile":105.34},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"54","median_amount":244.01,"10th_percentile":236.9,"90th_percentile":244.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.08,"10th_percentile":88.08,"90th_percentile":88.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"56","median_amount":262.19,"10th_percentile":253.33,"90th_percentile":262.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"45","median_amount":322.5,"10th_percentile":322.5,"90th_percentile":344.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"165","median_amount":164.7,"10th_percentile":164.69,"90th_percentile":168.87},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"279","median_amount":178.0,"10th_percentile":176.0,"90th_percentile":178.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"14","median_amount":88.08,"10th_percentile":82.75,"90th_percentile":88.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":168.87,"10th_percentile":168.87,"90th_percentile":168.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":105.34,"10th_percentile":96.92,"90th_percentile":105.34},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"1 through 10","median_amount":242.16,"10th_percentile":242.16,"90th_percentile":242.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Other Medicine","code_information":[{"code":"N809","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"18","median_amount":14.77,"10th_percentile":14.77,"90th_percentile":29.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"38","median_amount":16.17,"10th_percentile":14.7,"90th_percentile":45.57},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"21","median_amount":52.14,"10th_percentile":34.8,"90th_percentile":120.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"74","median_amount":38.28,"10th_percentile":30.63,"90th_percentile":76.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15.51,"10th_percentile":15.51,"90th_percentile":15.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"50","median_amount":15.51,"10th_percentile":15.51,"90th_percentile":31.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15.51,"10th_percentile":15.51,"90th_percentile":16.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":102.0,"10th_percentile":102.0,"90th_percentile":102.0},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":16.29,"10th_percentile":16.29,"90th_percentile":32.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"18","median_amount":30.39,"10th_percentile":28.07,"90th_percentile":60.78},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":89.27,"10th_percentile":44.64,"90th_percentile":89.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":15.0,"10th_percentile":13.52,"90th_percentile":42.09},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"13","median_amount":14.77,"10th_percentile":14.77,"90th_percentile":29.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":11.76,"10th_percentile":11.76,"90th_percentile":11.76},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":18.29,"10th_percentile":16.29,"90th_percentile":54.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"1 through 10","median_amount":15.31,"10th_percentile":15.31,"90th_percentile":15.31},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":104.4,"10th_percentile":104.4,"90th_percentile":104.4},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":15.51,"10th_percentile":15.51,"90th_percentile":15.51,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"47","median_amount":14.7,"10th_percentile":13.52,"90th_percentile":27.05},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"30","median_amount":46.6,"10th_percentile":42.36,"90th_percentile":84.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"17","median_amount":16.29,"10th_percentile":14.77,"90th_percentile":29.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"79","median_amount":46.86,"10th_percentile":42.6,"90th_percentile":85.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"20","median_amount":48.0,"10th_percentile":45.0,"90th_percentile":96.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":16.8,"10th_percentile":13.8,"90th_percentile":33.6},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"1 through 10","median_amount":45.87,"10th_percentile":45.87,"90th_percentile":45.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"1 through 10","median_amount":154.32,"10th_percentile":154.32,"90th_percentile":154.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":22.69,"10th_percentile":22.69,"90th_percentile":49.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":21.64,"10th_percentile":12.94,"90th_percentile":24.39},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-covered Services","code_information":[{"code":"N900","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":303.65,"10th_percentile":303.65,"90th_percentile":317.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":225.3,"10th_percentile":221.82,"90th_percentile":275.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":43.12,"10th_percentile":43.12,"90th_percentile":43.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":338.3,"10th_percentile":338.3,"90th_percentile":338.3},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":171.53,"10th_percentile":171.53,"90th_percentile":171.53},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"1 through 10","median_amount":175.03,"10th_percentile":175.03,"90th_percentile":197.86},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"14","median_amount":132.33,"10th_percentile":90.51,"90th_percentile":188.24},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.08,"10th_percentile":88.08,"90th_percentile":88.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":728.0,"10th_percentile":728.0,"90th_percentile":728.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":570.75,"10th_percentile":570.75,"90th_percentile":570.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"16","median_amount":111.44,"10th_percentile":107.46,"90th_percentile":205.47},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"16","median_amount":178.0,"10th_percentile":176.0,"90th_percentile":453.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":88.08,"10th_percentile":88.08,"90th_percentile":88.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Packaged Services","code_information":[{"code":"N902","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":162.77,"10th_percentile":162.77,"90th_percentile":162.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":65.88,"10th_percentile":64.01,"90th_percentile":69.4},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"21","median_amount":243.0,"10th_percentile":189.56,"90th_percentile":280.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"1 through 10","median_amount":220.0,"10th_percentile":119.18,"90th_percentile":220.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":149.56,"10th_percentile":149.56,"90th_percentile":149.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":178.71,"10th_percentile":178.71,"90th_percentile":183.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":231.42,"10th_percentile":231.42,"90th_percentile":231.42},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":59.95,"10th_percentile":59.95,"90th_percentile":118.63},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":208.3,"10th_percentile":197.89,"90th_percentile":208.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":40.93,"10th_percentile":40.93,"90th_percentile":40.93},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":162.77,"10th_percentile":162.77,"90th_percentile":162.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"1 through 10","median_amount":57.42,"10th_percentile":57.42,"90th_percentile":251.43},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":483.16,"10th_percentile":483.16,"90th_percentile":483.16,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"41","median_amount":59.95,"10th_percentile":22.15,"90th_percentile":65.9},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":177.54,"10th_percentile":177.54,"90th_percentile":177.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"1 through 10","median_amount":183.18,"10th_percentile":183.18,"90th_percentile":892.78,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"1 through 10","median_amount":199.0,"10th_percentile":125.4,"90th_percentile":302.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":69.1,"10th_percentile":64.4,"90th_percentile":194.58},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":65.9,"10th_percentile":60.63,"90th_percentile":65.9},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Not Recognized by OPPS","code_information":[{"code":"N905","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 57.80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"13","median_amount":3319.68,"10th_percentile":2882.32,"90th_percentile":3828.84},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"1 through 10","median_amount":3465.0,"10th_percentile":3465.0,"90th_percentile":12552.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5512] [Cardiac Cath (%BC): 58] [Lithotripsy (%BC): 58] [PTCA (%BC): 58] [Observation ($): 7343] [Critical Care ($): 5139] [Urgent Care ($): 185] [Clinic Visit ($): 72] [Cardiac Rehabilitation Therapy ($): 216] [Electrophysiologic Ablation (%BC): 58] [Electrophysiology and Mapping Studies (%BC): 58] [Sleep Studies-Attended ($): 3555] [Sleep Studies-Unattended ($): 3555] [CT Scan OP ($): 1578] [MRI OP ($): 2641] [Mammography-Diagnostic ($): 205] [Mammography-Screening ($): 205] [Positron Emission Tomography ($): 4406] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 551] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 298] [Physical Therapy ($): 298] [Speech Therapy ($): 298] [Mental Health-Intensive ($): 268] [Mental Health-Partial Hospitalization ($): 539] [OP ECT Mental Health ($): 645] [OP High Cost Drugs ($): FEE SCHEDULE] [Other Outpatient Implant (%BC): 48] [All Other OP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 6822] [Cardiac Cath (%BC): 79] [Lithotripsy (%BC): 79] [PTCA (%BC): 79] [Observation (%BC): 79] [Emergency Department (%BC): 79] [Critical Care (%BC): 79] [Urgent Care (%BC): 79] [Clinic Visit (%BC): 79] [Cardiac Rehabilitation Therapy (%BC): 79] [Electrophysiologic Ablation (%BC): 79] [Electrophysiology and Mapping Studies (%BC): 79] [Sleep Studies (%BC): 79] [CT Scan OP ($): 2244] [MRI OP ($): 3573] [Mammography-Diagnostic ($): 276] [Mammography-Screening ($): 276] [Positron Emission Tomography ($): 5957] [Radiology Fee Schedule: FEE SCHEDULE] [Ultrasound Imaging ($): 718] [Laboratory (%BC): 79] [Pathology (%BC): 79] [Occupational Therapy ($): 390] [Physical Therapy ($): 390] [Speech Therapy ($): 390] [Mental Health-Intensive ($): 263] [Mental Health-Partial Hospitalization ($): 530] [OP ECT Mental Health ($): 634] [OP High Cost Drugs (%BC): 79] [Other Outpatient Implant (%BC): 50] [All Other OP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":6652.6,"10th_percentile":6652.6,"90th_percentile":6652.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4821] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 33137] [Insertion of Permanent Pacemaker ($): 28341] [Joint Replacement-Full/Partial ($): 21175] [PTCA w/ Drug Eluting Stent ($): 30824] [PTCA w/non Drug Eluting Stent ($): 30542] [PTCA w/out stent ($): 25464] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13701] [ED Level 1--99281 ($): 378] [ED Level 2--99282 ($): 916] [ED Level 3--99283 ($): 1494] [ED Level 4--99284 ($): 2833] [ED Level 5--99285 ($): 5161] [Critical Care ($): 7364] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 315] [Cardiac Stress Test ($): 931] [Cardiology ($): 536] [Echocardiology ($): 2347] [EKG/ECG ($): 212] [Electrophysiology ($): 20069] [Electrophysiology Ablation ($): 64399] [Electrophysiology and Mapping Studies ($): 54975] [Holter Monitor/Telemetry ($): 1367] [Peripheral Vascular Lab ($): 1241] [EEG ($): 982] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 377] [Sleep Studies-Attended ($): 4864] [Sleep Studies-Unattended ($): 575] [Chemotherapy ($): 711] [Nuclear Medicine ($): 3570] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1990] [MRI OP ($): 3006] [Imaging Services ($): 451] [Mammography-Diagnostic ($): 339] [Mammography-Screening ($): 339] [Positron Emission Tomography ($): 5992] [Radiology ($): 479] [Ultrasound Imaging ($): 518] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 835] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 362] [Physical Therapy ($): 362] [Speech Therapy ($): 279] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 372] [Pulmonary Function ($): 1230] [Pulmonary Rehabilitation ($): 141] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4607] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 31739] [Insertion of Permanent Pacemaker ($): 27145] [Joint Replacement-Full/Partial ($): 20280] [PTCA w/ Drug Eluting Stent ($): 29523] [PTCA w/non Drug Eluting Stent ($): 29253] [PTCA w/out stent ($): 24387] [Stereotactic Radiosurgery (%BC): 83] [Stereotactic Radiosurgery-Fractionated (%BC): 83] [Observation ($): 13257] [ED Level 1--99281 ($): 370] [ED Level 2--99282 ($): 870] [ED Level 3--99283 ($): 1295] [ED Level 4--99284 ($): 2526] [ED Level 5--99285 ($): 4860] [Critical Care ($): 7074] [Urgent Care (%BC): 83] [Cardiac Rehabilitation Therapy ($): 300] [Cardiac Stress Test ($): 892] [Cardiology ($): 514] [Echocardiology ($): 2248] [EKG/ECG ($): 203] [Electrophysiology ($): 19220] [Electrophysiology Ablation ($): 61687] [Electrophysiology and Mapping Studies ($): 52660] [Holter Monitor/Telemetry ($): 1281] [Peripheral Vascular Lab ($): 1190] [EEG ($): 940] [EMG (%BC): 83] [MEG (%BC): 83] [Neuropsychological Testing and Biofeedback ($): 359] [Sleep Studies-Attended ($): 4658] [Sleep Studies-Unattended ($): 561] [Chemotherapy ($): 653] [Nuclear Medicine ($): 3439] [Oncology (%BC): 83] [Radiation Therapy  (%BC): 83] [CT Scan OP ($): 1951] [MRI OP ($): 2898] [Imaging Services ($): 433] [Mammography-Diagnostic ($): 324] [Mammography-Screening ($): 324] [Positron Emission Tomography ($): 5735] [Radiology ($): 456] [Ultrasound Imaging ($): 484] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 800] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 83] [Occupational Therapy ($): 346] [Physical Therapy ($): 346] [Speech Therapy ($): 266] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 83] [Ambulance--Land  (%BC): 83] [Hyperbarics (%BC): 83] [IV Therapy ($): 354] [Pulmonary Function ($): 1175] [Pulmonary Rehabilitation ($): 135] [All Other OP (%BC): 83]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 4209] [Insertion of Automatic Implantable Cardiac Defibrillator (AICD) ($): 30372] [Insertion of Permanent Pacemaker ($): 25959] [Joint Replacement-Full/Partial ($): 19366] [PTCA w/ Drug Eluting Stent ($): 28243] [PTCA w/non Drug Eluting Stent ($): 27983] [PTCA w/out stent ($): 23311] [Stereotactic Radiosurgery (%BC): 78] [Stereotactic Radiosurgery-Fractionated (%BC): 78] [Observation ($): 12362] [ED Level 1--99281 ($): 336] [ED Level 2--99282 ($): 808] [ED Level 3--99283 ($): 1198] [ED Level 4--99284 ($): 2384] [ED Level 5--99285 ($): 2384] [Critical Care ($): 6798] [Urgent Care (%BC): 78] [Cardiac Rehabilitation Therapy ($): 261] [Cardiac Stress Test ($): 836] [Cardiology ($): 493] [Echocardiology ($): 2160] [EKG/ECG ($): 196] [Electrophysiology ($): 18348] [Electrophysiology Ablation ($): 59131] [Electrophysiology and Mapping Studies ($): 50462] [Holter Monitor/Telemetry ($): 1138] [Peripheral Vascular Lab ($): 1142] [EEG ($): 903] [EMG (%BC): 78] [MEG (%BC): 78] [Neuropsychological Testing and Biofeedback ($): 298] [Sleep Studies-Attended ($): 4450] [Sleep Studies-Unattended ($): 510] [Chemotherapy ($): 597] [Nuclear Medicine ($): 2850] [Oncology (%BC): 78] [Radiation Therapy  (%BC): 78] [CT Scan OP ($): 1818] [MRI OP ($): 2543] [Imaging Services ($): 415] [Mammography-Diagnostic ($): 311] [Mammography-Screening ($): 311] [Positron Emission Tomography ($): 5184] [Radiology ($): 411] [Ultrasound Imaging ($): 409] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis ($): 768] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 78] [Occupational Therapy ($): 333] [Physical Therapy ($): 333] [Speech Therapy ($): 254] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [Other Outpatient Implant (%BC): 0 Charge Threshold 1000 (%BC): 55] [Ambulance--Air  (%BC): 78] [Ambulance--Land  (%BC): 78] [Hyperbarics (%BC): 78] [IV Therapy ($): 312] [Pulmonary Function ($): 1101] [Pulmonary Rehabilitation ($): 130] [All Other OP (%BC): 78]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"percent of total billed charges","standard_charge_percentage":44.85,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery Group ($): FEE SCHEDULE] [OP Surg. Ungroupable (%BC): 74.4] [Observation (%BC): 74.4] [Emergency Department (%BC): 74.4] [CT Scan OP ($): 1826] [MRI OP ($): 2130] [Mammography-Diagnostic ($): 186] [Ultrasound Imaging ($): 468] [Occupational Therapy ($): 91] [Physical Therapy ($): 91] [Respiratory Services/Therapy  (%BC): 74.4] [Speech Therapy (%BC): 74.4] [Other Outpatient Implant (%BC): 74.4] [All Other OP (%BC): 74.4]","count":"1 through 10","median_amount":4265.37,"10th_percentile":4265.37,"90th_percentile":4265.37,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 76] [Observation (%BC): 76] [Emergency Department (%BC): 76] [Occupational Therapy (%BC): 76] [Physical Therapy (%BC): 76] [Respiratory Services/Therapy  (%BC): 76] [Speech Therapy (%BC): 76] [OP High Cost Drugs ($): FEE SCHEDULE] [All Other OP (%BC): 76]","count":"1 through 10","median_amount":4742.16,"10th_percentile":4742.16,"90th_percentile":5011.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"11","median_amount":3808.0,"10th_percentile":2186.09,"90th_percentile":4420.0},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":17.25,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"84","median_amount":3624.92,"10th_percentile":2593.08,"90th_percentile":4066.3},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surg. Group 0 ($): FEE SCHEDULE] [OP Surg. Group 1 ($): FEE SCHEDULE] [OP Surg. Group 2 ($): FEE SCHEDULE] [OP Surg. Group 3 ($): FEE SCHEDULE] [OP Surg. Group 4 ($): FEE SCHEDULE] [OP Surg. Group 5 ($): FEE SCHEDULE] [OP Surg. Group 6 ($): FEE SCHEDULE] [OP Surg. Group 7 ($): FEE SCHEDULE] [OP Surg. Group 8 ($): FEE SCHEDULE] [OP Surg. Group 9 ($): FEE SCHEDULE] [OP Surg. Group 10 ($): FEE SCHEDULE] [OP Surg. Ungroupable ($): 5086] [Observation ($): 11362.24] [ED Level 1--99281 ($): 636.54] [ED Level 2--99282 ($): 1253.98] [ED Level 3--99283 ($): 2164.24] [ED Level 4--99284 ($): 4455.78] [ED Level 5--99285 ($): 4869.53] [Critical Care ($): 5410.59] [Nuclear Medicine ($): 3871.22] [CT Scan OP ($): 2089.97] [MRI OP ($): 2652.25] [Imaging Services ($): 445.58] [Mammography-Diagnostic ($): 244.01] [Mammography-Screening ($): 244.01] [Positron Emission Tomography ($): 6895.85] [Radiology ($): 530.84] [Ultrasound Imaging ($): 597.29] [Occupational Therapy ($): 341.61] [Physical Therapy ($): 341.61] [Speech Therapy ($): 341.61] [Other Outpatient Implant ($): 0 Charge Threshold 1000 (%BC): 69.3] [All Other OP (%BC): 70.6]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 71] [Observation (%BC): 71] [Emergency Department (%BC): 71] [Nuclear Medicine ($): 3925.01] [CT Scan OP ($): 2660.58] [MRI OP ($): 3718.36] [Imaging Services ($): 399.08] [Mammography-Diagnostic ($): 262.19] [Mammography-Screening ($): 262.19] [Positron Emission Tomography ($): 7316.62] [Ultrasound Imaging ($): 665.15] [Occupational Therapy ($): 379.72] [Physical Therapy ($): 379.72] [Respiratory Services/Therapy  (%BC): 71] [Speech Therapy ($): 379.72] [All Other OP (%BC): 71]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other OP (%BC): 12.77]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 75] [Observation (%BC): 75] [Emergency Department (%BC): 75] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy (%BC): 75] [Physical Therapy (%BC): 75] [Respiratory Services/Therapy  (%BC): 75] [Speech Therapy (%BC): 75] [OP High Cost Drugs Fee Schedule: FEE SCHEDULE] [All Other OP (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":80.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"43","median_amount":2444.66,"10th_percentile":690.0,"90th_percentile":3055.67},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 69.50] [Stereotactic Radiosurgery (%BC): 69.50] [Stereotactic Radiosurgery-Fractionated (%BC): 69.50] [Observation (%BC): 69.50] [Urgent Care (%BC): 69.50] [Cardiac Rehabilitation Therapy (%BC): 69.50] [Cardiac Stress Test (%BC): 69.50] [Cardiology (%BC): 69.50] [Echocardiology (%BC): 69.50] [EKG/ECG  (%BC): 69.50] [Holter Monitor/Telemetry (%BC): 69.50] [Peripheral Vascular Lab (%BC): 69.50] [EEG (%BC): 69.50] [EMG (%BC): 69.50] [MEG (%BC): 69.50] [Neuropsychological Testing and Biofeedback (%BC): 69.50] [Sleep Studies (%BC): 69.50] [Chemotherapy (%BC): 69.50] [Nuclear Medicine ($): 2525] [Oncology (%BC): 69.50] [Radiation Therapy  (%BC): 69.50] [CT Scan OP ($): 1792] [MRI OP ($): 2553] [Imaging Services ($): 244] [Mammography-Diagnostic ($): 178] [Mammography-Screening ($): 178] [Positron Emission Tomography ($): 5083] [Radiology ($): 244] [Ultrasound Imaging ($): 430] [Laboratory Fee Schedule: FEE SCHEDULE] [Pathology Fee Schedule: FEE SCHEDULE] [Hemodialysis (%BC): 69.50] [Peritoneal Dialysis, CAPD, and CCPD (%BC): 69.50] [Occupational Therapy ($): 287] [Physical Therapy ($): 287] [Respiratory Services/Therapy  (%BC): 69.50] [Speech Therapy ($): 287] [OP High Cost Drugs ($): FEE SCHEDULE] [Ambulance--Air  (%BC): 69.50] [Ambulance--Land  (%BC): 69.50] [Hyperbarics (%BC): 69.50] [IV Therapy (%BC): 69.50] [Pulmonary Function (%BC): 69.50] [Pulmonary Rehabilitation (%BC): 69.50]","count":"41","median_amount":7099.0,"10th_percentile":5129.6,"90th_percentile":9630.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Observation ($): 1150] [Mental Health-Intensive ($): 216] [Mental Health-Partial Hospitalization ($): 433] [OP ECT Mental Health ($): 750]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1750.0,"10th_percentile":1750.0,"90th_percentile":2000.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"percent of total billed charges","standard_charge_percentage":23.0,"count":"1 through 10","median_amount":1402.65,"10th_percentile":268.96,"90th_percentile":2599.85},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[Radiology Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): FEE SCHEDULE] [Physical Therapy ($): FEE SCHEDULE] [Speech Therapy ($): FEE SCHEDULE] [All Other OP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [OP Surgery  (%BC): 72.20] [Observation (%BC): 72.20] [Emergency Department (%BC): 72.20] [Nuclear Medicine ($): 3435.15] [CT Scan OP ($): 2544.56] [MRI OP ($): 3689.61] [Mammography-Diagnostic ($): 250.64] [Mammography-Screening ($): 250.64] [Positron Emission Tomography ($): 7073.87] [Radiology ($): 381.69] [Ultrasound Imaging ($): 508.91] [Occupational Therapy ($): 362.60] [Physical Therapy ($): 362.60] [Respiratory Services/Therapy  (%BC): 72.20] [Speech Therapy ($): 362.60] [All Other OP (%BC): 72.20]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Mcc","code_information":[{"code":"077","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Cc","code_information":[{"code":"078","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy Without Cc/Mcc","code_information":[{"code":"079","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Or Device Replacement With Mcc","code_information":[{"code":"210","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Or Device Replacement Without Mcc","code_information":[{"code":"211","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis With Cc/Mcc","code_information":[{"code":"294","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis Without Cc/Mcc","code_information":[{"code":"295","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System O.R. Procedures With Mcc","code_information":[{"code":"361","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System O.R. Procedures Without Mcc","code_information":[{"code":"362","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection","code_information":[{"code":"400","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Or Knee Procedures With Principal Diagnosis Of Periprosthetic Joint Infection With Mcc Or Insert","code_information":[{"code":"403","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Or Knee Procedures With Principal Diagnosis Of Periprosthetic Joint Infection Without Mcc","code_information":[{"code":"404","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Prosthesis","code_information":[{"code":"449","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Mcc","code_information":[{"code":"453","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Cc","code_information":[{"code":"454","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","code_information":[{"code":"455","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"459","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"460","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Arthroscopy","code_information":[{"code":"509","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Or Complex Spinal Fusion Procedures Except Cervical With Mcc","code_information":[{"code":"523","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Or Complex Spinal Fusion Procedures Except Cervical With Cc","code_information":[{"code":"524","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Or Complex Spinal Fusion Procedures Except Cervical Without Cc/Mcc","code_information":[{"code":"525","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Malignancy With Mcc","code_information":[{"code":"731","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Malignancy With Cc","code_information":[{"code":"732","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Malignancy Without Cc/Mcc","code_information":[{"code":"733","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Principal Diagnosis Invalid As Discharge Diagnosis","code_information":[{"code":"998","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ungroupable","code_information":[{"code":"999","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"Auto","plan_name":"Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 18.43]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Access PPO","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Preferred / Blue Preferred Plus HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 2652] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 12545 Days: 4 Additional Days: 1593] [Normal vag. Del. 4 day stay-Case Rate: 7561 Days: 4 Additional Days: 1593] [Normal Newborn-Per Diem: 1229] [Lower Level Neonate-Per Diem: 1733] [Higher Level Neonate-Per Diem: 2477] [Severe Level Neonate-per diem: 2477] [Alcohol/ Chemical Dependency-Per Diem: 1905] [Psych-Per Diem: 1905] [Rehab-Per Diem: 2236] [All Other IP (%BC): 58]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Blue Traditional Traditional","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Alcohol/ Chemical Dependency-Per Diem: 1869] [Psych-Per Diem: 1869] [All Other IP (%BC): 79]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centene Behavioral Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Broad(WI1) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 6216] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 12360 Days: 4 Additional Days: 1295] [Normal vag. Del. 2 day stay-Case Rate: 7004 Days: 2 Additional Days: 1295] [Normal Newborn-Per Diem: 1208] [Lower Level Neonate-Per Diem: 1468] [Higher Level Neonate-Per Diem: 1899] [Severe Level Neonate-per diem: 2331] [Psych-Per Diem: 1640] [Rehab-Per Diem: 2158] [SNF-(% BC): 65] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Median(WI2) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5925] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11804 Days: 4 Additional Days: 1236] [Normal vag. Del. 2 day stay-Case Rate: 6731 Days: 2 Additional Days: 1236] [Normal Newborn-Per Diem: 1154] [Lower Level Neonate-Per Diem: 1401] [Higher Level Neonate-Per Diem: 1814] [Severe Level Neonate-per diem: 2226] [Psych-Per Diem: 1567] [Rehab-Per Diem: 2061] [SNF-(% BC): 63] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Centivo","plan_name":"Value(WI3) Other Commercial Plan","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 5433] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE Days: 12] [C-Section 4 day stay-Case Rate: 11445 Days: 4 Additional Days: 1199] [Normal vag. Del. 2 day stay-Case Rate: 6367 Days: 2 Additional Days: 1199] [Normal Newborn-Per Diem: 1119] [Lower Level Neonate-Per Diem: 1359] [Higher Level Neonate-Per Diem: 1758] [Severe Level Neonate-per diem: 2158] [Psych-Per Diem: 1518] [Rehab-Per Diem: 1998] [SNF-(% BC): 60] [Burn  (%BC): 75]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Chorus","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 2210.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"DOC","plan_name":"Government","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 6389.92] [Surgical-Per Diem: 6389.92] [Swing Bed-Per Diem: 4259.22]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"FABOH","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 67704 | Total % of Charge: 74.4] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 8498] [Normal Vaginal Delivery-Case Rate: 5075] [Normal Newborn-Case Rate: 2181.22] [Lower Level Neonate-Per Diem: 1789] [Higher Level Neonate-Per Diem: 1816] [Nursery  Level 1- Boarder-Per Diem: 707] [IP Prosthetics/Implants/Devices (%BC): 74.4]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"First Health/Coventry","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Health Payment Systems","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges < BasePayment | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"ICARE","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"MOLINA","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 2483.13] [Surgical-Per Diem: 2483.13] [Swing Bed-Per Diem: 2163.25]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"Complementary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"HealthEOS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":87.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Multiplan","plan_name":"PHCS Primary Network All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.86]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Network Health Plan","plan_name":"HMO/POS","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 8114.09] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 13261.25 Days: 4 Additional Days: 2571.79] [Normal vag. Del. 2 day stay-Case Rate: 7714.15 Days: 2 Additional Days: 2571.79] [Normal Newborn-Per Diem: 1542.83] [Lower Level Neonate-Per Diem: 1928.23] [Higher Level Neonate-Per Diem: 2652.25] [Severe Level Neonate-per diem: 2652.25] [Rehab-Per Diem: 2571.79] [SNF-Per Diem: 541] [Hospice-Per Diem: 954.81] [All Other IP (%BC): 68]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Quartz Health Solutions","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > BasePayment * 3 | Excess % of Charge: 73] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Self Pay","plan_name":"Uninsured","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 17.27]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Sheboygan Employer Health Network","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":75.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"The Alliance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 12 days | Excess % of Charge: 7200] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 17499 Days: 4 Additional Days: 1500] [Normal vag. Del. 2 day stay-Case Rate: 7765 Days: 2 Additional Days: 1500] [Normal Newborn-Per Diem: 1250] [Lower Level Neonate-Per Diem: 1450] [Higher Level Neonate-Per Diem: 2000] [Severe Level Neonate-per diem: 3600] [All Other IP (%BC): 80]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Trilogy","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 25000 | Total % of Charge: 80] [MSDRG Base Rate: FEE SCHEDULE] [Alcohol/ Chemical Dependency-Per Diem: 2316] [Psych-Per Diem: 2316] [SNF-Per Diem: 863]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 15 days | Excess % of Charge: 5674] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section-Case Rate: 13198] [Normal Vaginal Delivery-Case Rate: 7201] [Normal Newborn-Per Diem: 1144] [Lower Level Neonate-Per Diem: 1551] [Higher Level Neonate-Per Diem: 2243] [Severe Level Neonate-per diem: 2871] [Rehab-Per Diem: 2409] [SNF-Per Diem: 1084] [Hospice-Per Diem: 925]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Behavioral Health Plan","methodology":"other","standard_charge_algorithm":"[Lesser Than Charges paid at %: 100] [Medical-Per Diem: 1457] [Alcohol/ Chemical Dependency-Per Diem: 1457] [Psych-Per Diem: 1457]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Community Care Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care - Behavioral Health","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wellcare","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Medical-Per Diem: 3310.84] [Surgical-Per Diem: 3310.84] [Swing Bed-Per Diem: 2206.85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Workers Comp","plan_name":"Workers Compensation Plan","methodology":"other","standard_charge_algorithm":"[All Other IP (%BC): 90]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"WPS Health Insurance","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > 10 days | Excess % of Charge: 5343.57] [Lesser Than Charges paid at %: 100] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 14249.53 Days: 4 Additional Days: 2035.65] [Normal vag. Del. 4 day stay-Case Rate: 8142.58 Days: 4 Additional Days: 2035.65] [Normal Newborn-Per Diem: 1145.05] [Lower Level Neonate-Per Diem: 1653.96] [Higher Level Neonate-Per Diem: 2417.33] [Severe Level Neonate-per diem: 2417.33] [Psych-Case Rate: 5470.80 Days: 3 Additional Days: 1781.19] [Rehab-Per Diem: 2162.88]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]}]}